Care Home: Kilburn Care Centre

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What the care home does well Comments made by the people living at Kilburn Care centre were positive. Such as " I`m very happy with the care, the staff are lovely and the food is very good". And " the staff are very kind and very helpful to me". Observations of staff with the people living at the home demonstrated a caring and courteous approach. The service is very good at reporting any incidents or accidents and recording any complaints made and how these have been addressed. This demonstrates an `open` and inclusive approach. What has improved since the last inspection? All of the five requirements left at the last key inspection have been met. The hours worked by the activities coordinator has been increased which enables more time is provided in meeting the recreational and social needs of the people who live at the home. What the care home could do better: Although there was a good range of activities offered, there were comments that the activities available didn`t meet the needs of everyone living at Kilburn Care Centre. Information regarding special diets and dietary preferences was not readily available to the catering team. This meant that the catering team did not always know if someone required special diets, such as a diabetic diet. It also indicated that the catering team were not aware of each persons preferred meal choices. This has the potential to result in individual`s being provided with meals that were unsuitable in meeting their dietary and health care needs, which would have a detrimental effect on their physical well-being. Although the views and opinions of the people living at the home and their representatives were sought. There were no records to show that any suggestions or ideas made were acted upon. CARE HOMES FOR OLDER PEOPLE Kilburn Care Centre Dale Park Avenue Kilburn Belper Derbyshire DE56 0NR Lead Inspector Angela Kennedy Unannounced Inspection 9th April 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kilburn Care Centre DS0000058025.V362157.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kilburn Care Centre DS0000058025.V362157.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kilburn Care Centre Address Dale Park Avenue Kilburn Belper Derbyshire DE56 0NR 01332 880644 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) kilburnnursing@schealthcare.co.uk www.southerncrosshealthcare.co.uk Southern Cross Care Homes No 2 Limited Vacant Care Home 49 Category(ies) of Old age, not falling within any other category registration, with number (49) of places Kilburn Care Centre DS0000058025.V362157.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. To admit one (named) service user under the age of 65 years in the category of PD. One DE(E) place for the service user named in the notice of proposal letter dated 24/11/04. One DE(E) place for the service user (EM) as named in the notice of proposal letter dated 05/05/05. The registered person will be responsible for informing the Commission for Social Care Inspection when the named individuals no longer reside at Kilburn Care Centre. 17th April 2007 Date of last inspection Brief Description of the Service: Kilburn Care Centre is in a village location, close to local shops, churches, pubs and other facilities. The home was two homes, which have been joined to create one registered home. One was a converted building, the other purpose built. Currently the converted building has residents requiring personal care and the purpose built section has residents requiring nursing care. The home can accommodate up to 49 older people. Most of the bedrooms are single and have en-suite facilities. There is a garden area to the rear of the home and car parking to the front. Weekly fees charged at the home range were, Funded residents: Residential care £352. Nursing care £496.69 Private residents: Residential care £524.41Nursing care £635.12 Additional costs not included in the weekly fees included: Hairdressing, Chiropody and Toiletries. Further information regarding the fees is available within the homes service user guide and by contacting the manager at Kilburn Care Centre. Kilburn Care Centre DS0000058025.V362157.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This key inspection was unannounced and took place over approximately eight hours. Key inspections take into account a wide range of information and commence before the site visit by examining previous reports and information such as any reported incidents. The site visit is used to see how the service is performing in practice and to meet with the people using the service. The inspection was focused on assessing compliance with defined key National Minimum Standards. An Annual Quality Assurance Assessment (AQAA) had been completed by the service prior to this inspection visit. The information provided in the AQAA was used in assessing how the service meets the defined key national minimum standards. The manager was on duty on the day of the inspection visit. Some of the people living at Kilburn Care Centre were spoken with, regarding the care, support and services provided to them. Two visitors were spoken with regarding the care, support and services provided to their relatives. Staff were spoken with to ascertain their views on the care and services provided, and their opinion of the training and support offered to them. Thirty-six people were residing at Kilburn care at the time of this inspection visit. At this inspection visit three people were case tracked. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at care plans and other documents relating to that persons care, talking to staff regarding the care they provide and if possible talking to the individual. Two of the people case tracked were able to discuss their opinion of the service and support provided to them. Kilburn Care Centre DS0000058025.V362157.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Although there was a good range of activities offered, there were comments that the activities available didn’t meet the needs of everyone living at Kilburn Care Centre. Information regarding special diets and dietary preferences was not readily available to the catering team. This meant that the catering team did not always know if someone required special diets, such as a diabetic diet. It also indicated that the catering team were not aware of each persons preferred meal choices. This has the potential to result in individual’s being provided with meals that were unsuitable in meeting their dietary and health care needs, which would have a detrimental effect on their physical well-being. Although the views and opinions of the people living at the home and their representatives were sought. There were no records to show that any suggestions or ideas made were acted upon. Kilburn Care Centre DS0000058025.V362157.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kilburn Care Centre DS0000058025.V362157.R01.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 Kilburn Care Centre DS0000058025.V362157.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was a good assessment system in place. This means that individuals moving into the home could be confident that their needs could be met. EVIDENCE: Assessments were in place for each person case tracked. The care records of the three people case tracked were examined. All included a range of assessment information that provided an accurate assessment of their needs. This demonstrates that the people living at Kilburn care can be confident that the staff and facilities at the home are able to support them. A record of six monthly reviews was also seen in the two care files looked at. The reviews demonstrated that the individual and their family had been involved in these reviews. However it was noted that the information recorded in the reviews was limited, which did not clearly demonstrate that a thorough Kilburn Care Centre DS0000058025.V362157.R01.S.doc Version 5.2 Page 10 review of needs had been undertaken. One person had not lived at the service long enough to have had a six monthly review. One visitor confirmed they had received information about the service prior to their relative being living at the home and had been able to look around the service before making a decision about the service. Another visitor confirmed that due to the nature of their relative’s admission they didn’t have the opportunity to visit the home before they moved into the home. They did confirm that they had received information about the services and care provided at Kilburn Care Centre. All of the people spoken with, both visitors and those living at the home said they received the support and information they needed to help with their transition into the home. Kilburn Care Centre does not provide intermediate care; therefore standard 6 does not apply to this service. Kilburn Care Centre DS0000058025.V362157.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual’s support needs were set out within their plan of care and demonstrated that health care needs were met. EVIDENCE: People’s health and personal care needs are met. The home has a plan of care that the person or someone close to them has been involved in making. For example one person case tracked did not speak English as their first language and their English vocabulary was limited. However the detailed care plan regarding this clearly directed the staff on the actions they needed to take to ensure this person was understood and able to understand others. This individual was spoken to and confirmed that the staff team met their needs and that they were able to make their needs known to staff. Kilburn Care Centre DS0000058025.V362157.R01.S.doc Version 5.2 Page 12 Individual’s needs may not be met in regard to each person’s religious, spiritual and social preferences and needs, as within the care plans seen there was limited information to address these areas. People’s safety was maintained as any areas of care or daily life that had been identified as a risk had been regularly assessed and appropriate actions taken to reduce the risks Those spoken with, both people living at the home and their relatives were generally positive about the care and support provided at the home. Comments included, “ the staff are lovely” and “the staff are very kind” One relative discussed recent concerns that they had regarding some aspects of their relatives care. However this person stated that these concerns appeared to have been addressed at the present time. Records demonstrated that health care needs were met. This included visits from G.P’s, district nurses, chiropodist and optician. The GP visited the home every Thursday for a ‘mini surgery’, and other times as required. Assessments were also seen from speech and language therapists and other health care professionals. This demonstrated that individuals were referred to the appropriate health care professionals as required. In general the medication practices were satisfactory, but the clinical fridge temperature recordings for medications requiring cold storage were not been recorded correctly. Potentially this could result in this medication not being effective when administered, if it is not stored at the correct temperature. The Medication Administration Records, (MARs), were checked for the three people case tracked. All were correctly completed, indicating that people received their medication as prescribed. One did not include a photograph and it was stated that this was because this person had been admitted to the service within the last month. However the purpose of a photograph is to ensure that staff can clearly identify each individual prior to administering medication. This is more beneficial when new people are admitted to the service, as staff will not ‘know them’. It was noticed that the records of medication disposal on the nursing side had not been countersigned. This is recommended as a good practice measure, to demonstrate that medications are disposed of correctly. Countersignatures were in place in the records of disposed medicines on the residential side of the home. In general the people spoken with felt that staff were respectful of individual’s living at the home and ensured their privacy and dignity was maintained. Staff observed behaved courteously towards people living at the home and appeared to have a good rapport. Kilburn Care Centre DS0000058025.V362157.R01.S.doc Version 5.2 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. 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. Activities were available but they were not sufficient to meet the social needs of everyone, which meant that some people lacked social and recreational stimulation. Although most people enjoyed the quality and variety of meals, the service did not ensure that people requiring specific diets were catered for satisfactorily. EVIDENCE: There was an activities coordinator working for 35 hours per week, however the activities coordinator was not on duty at the time of this inspection visit. Individual social profiles were in place within the activities folder. The records seen indicated that activities only took place when the activities coordinator was on duty. This suggests that the people living at the home were not always provided with sufficient social or recreational stimulation to promote their well being. Kilburn Care Centre DS0000058025.V362157.R01.S.doc Version 5.2 Page 14 Discussions with some people living at the home indicated that the activities provided were good. These included trips out, chair based exercises, arts and crafts and nail care. People spoken with indicated that they chose when they wished to join in with activities. One of the relatives spoken with felt there was little for their mother to do. This person stated that they had spoken to the activities coordinator with suggestions of activities for their mother. The local vicar visited Kilburn Care Centre every month. The manager confirmed that one of the people living at the home attended church services every week, at their chosen Church and was able to do so using the local taxi service. Visiting hours were open at Kilburn and the visitors spoken with confirmed that staff made them feel welcome. People were able to choose where they spent time with their visitors, but it was noted that people chose not to use the quiet areas with the home. The menus were looked at and demonstrated that more than one choice of meal was offered at each mealtime. From the discussions held with some of the people living at the home it was confirmed that the meals were enjoyed. It was stated that there was plenty of variety and the meals were of a good quality. It was stated that no specific diets were required other than ‘soft’ diets. Discussions took place as to how soft diets were prepared and presented. From the discussions held it appeared that the variety of meals for people requiring soft diets was limited. From reviewing other records it was identified that there was a person living at the home that required a diabetic diet. However staff working in the kitchen did not seem to be aware of this. On discussions with a member of staff it was confirmed that records regarding who required a special diet was not kept in the kitchen. This has the potential to result in individual’s being provided with meals that were unsuitable in meeting their dietary and health care needs, which would have a detrimental effect on their physical well being. Kilburn Care Centre DS0000058025.V362157.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The views of the people living at the home were listened to and acted upon. The systems in place safeguarded the people living at the home from abuse EVIDENCE: The complaints records were seen and demonstrated that there had been seven complaints made to the home since its last key inspection. Records were seen to demonstrate that these complaints had been addressed appropriately. Both those living at the home and visitors spoken with said they were confident that there concerns would be addressed. We have received five complaints about the service since the last key inspection. Four of these complaints were returned to the service to investigate using their complaints procedure and we were informed of the outcome of these investigations, which we were satisfied had been addressed satisfactorily. One of the complaints we received led us to undertake a random inspection in October 2007. During this inspection visit 2 residents, a visitor and 4 staff were spoken with. Staff records and accident records were examined. Kilburn Care Centre DS0000058025.V362157.R01.S.doc Version 5.2 Page 16 Working practices were observed. There was no evidence found to support the complaint we received. The recently appointed home manager confirmed that she had undertaken a two and three day managers training course in safeguarding adults. Records were also seen regarding the staff team undertaking safeguarding training and showed that twenty-two members of staff have undertaken this training. Four staff was due to undertake this training. Staff spoken with had a good understanding of safeguarding adults and the procedure to follow in the event of suspected or alleged abuse. This ensures that the people living at the home are protected from abuse. The homes safeguarding policy was seen and linked with the local authority procedure, who are the lead investigators in safeguarding adults. Kilburn Care Centre DS0000058025.V362157.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical appearance in some areas of the home does not promote the well being of the people living there. EVIDENCE: A tour of the home was undertaken. Some areas of the home that were seen required redecoration to improve the physical appearance for the people living there. For example, wallpaper that was worn and removed in some areas. The base of the floor around the wash hand basin in toilet of room 6 required repair and the floor of this room required resealing. Kilburn Care Centre DS0000058025.V362157.R01.S.doc Version 5.2 Page 18 It was confirmed that some new furniture and carpets had been ordered and some already purchased. This included new carpets for the lounge area and coffee tables and new carpet for the stairs leading to the top floor and six bedrooms. A hair salon was provided and on the top floor, which provided a purposeful setting for people to have their hair cut and styled. A lounge area was used for care reviews and activities such as hand massages. At the last key inspection it was identified that there were 2 bathrooms on the ground floor out of use because the bath hoists were awaiting repair. These had been repaired. However on the day of this visit the hoist in the bathroom of room 4 had broken down and it was confirmed that this was waiting to be repaired. The laundry room was seen and housed to washers and two tumble driers. Clothes were separated into individual laundry baskets and returned to each person’s room. Visitors and people living at the home said they were happy with the laundry service and said that clothes were well laundered. One visitor did say that she occasionally found clothes in her relative’s wardrobe that did not belong to her relative. All of the people living at Kilburn Care were dressed appropriately on the day of this visit and their clothing appeared well laundered. This can enhance individual’s well being by promoting confidence and self worth. People spoken with said the standards of hygiene were in general satisfactory. No offensive smells were noted in the communal areas of the home, however it was noted that one bedroom seen did smell of urine. The manager also noted this and it was confirmed that the carpet required cleaning. The maintenance person was on duty on the day of this visit and was seen undertaking maintenance duties. Kilburn Care Centre DS0000058025.V362157.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment practices and training provided ensured that the people living at the home were protected and supported by a competent staff team. EVIDENCE: Staff rotas demonstrated that at the present time with occupancy of 36 people sufficient numbers of staff were rostered on duty. This ensures that people have appropriate support as there is enough competent staff on duty at all times. It was stated that when there was full occupancy at the home the staffing levels in the morning and at night would be increased to reflect this and ensure needs could be met. Visitors and people living at the home that were spoken with felt the staffing levels were sufficient to meet their needs. Staff spoken with were generally satisfied with staffing levels. People living at the home can be confident that the staff in the home are suitable to care for them as the recruitment records of three members of staff Kilburn Care Centre DS0000058025.V362157.R01.S.doc Version 5.2 Page 20 were looked at and included all the required information, such as Criminal Records Bureau disclosures and 2 written references. People living at the home can be confident that their needs are met by staff that are given the relevant training. There were records of staff induction and training. The induction programme was based on the Skills for Care standards. The records seen included evidence of how staff had achieved competence in all of the stated areas. Staff training records showed that the majority of staff were up to date in all mandatory training such as moving and handling and fire safety. Up to date records demonstrated that staff were provided with training that was relevant to their job and supported them in meeting the needs of the people living at the home. Staff spoken with said that the training provided was very good and confirmed that it supported them in meeting the needs of the people they cared for. Records showed that ten staff had achieved a National Vocational Qualification (NVQ) in care at level 2 and two had achieved an NVQ in care at level 3. There was seven care staff undertaking NVQ2 and three staff undertaking NVQ3. Kilburn Care Centre DS0000058025.V362157.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, safety and welfare of the people living at the home and visitors and staff were safeguarded by the practices in place. EVIDENCE: In the last twelve months thirty-three members of staff had left employment at Kilburn Care Centre. This had caused some instability within the staff team and this was reflected in the discussions with staff at this visit. However from discussions with staff, some who had recently returned to Kilburn Care, it was clear that the staff were confident regarding the new manager’s ability to manage the service. All of the comments made were extremely positive regarding the new manager’s ability and approach to the Kilburn Care Centre DS0000058025.V362157.R01.S.doc Version 5.2 Page 22 staff and the service. This indicates that the people living at the home can be confident that the home is led and managed appropriately. Some of the quality assurance systems were looked at. These included recent surveys that had been completed by relatives of the people living at the home. There was no report seen of the analysis of quality assurance measures and any actions that had been taken to address any issues raised. Once this has been undertaken this will demonstrate that the running of the home and the services provided are influenced by the people that live there. Suitable systems were in place for individual’s personal money held by the home. This ensured their financial interests were safeguarded and demonstrates that care home manages individual’s money in their best interests. The environment is safe for people and staff because appropriate health and safety checks are carried out. Health and safety records were sampled, including the fire log book, accident book, and maintenance records. All the records seen were up to date and corresponded with information provided by the home prior to this visit. Kilburn Care Centre DS0000058025.V362157.R01.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 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 3 X 3 X 3 X X 3 Kilburn Care Centre DS0000058025.V362157.R01.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 OP15 Regulation 17 (1) (a) 17 (2) Requirement Timescale for action 01/06/08 2 OP19 23 (2) (b) To ensure dietary and health care needs are met, records of special therapeutic diets must be made available to the catering team. The redecoration and renovation 01/08/08 of the home must be undertaken on a continuous basis, to ensure the environment is maintained to a good standard for the people living there. 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. Refer to Standard OP7 OP9 Good Practice Recommendations Information on each persons spiritual, social and religious preferences and how these are to be met should be recorded in their care plan. The minimum and maximum daily temperatures of the medication fridge should be recorded to ensure medication is stored at the correct temperature and is fit to be given to residents. DS0000058025.V362157.R01.S.doc Version 5.2 Page 25 Kilburn Care Centre 3. 4 OP12 OP15 Further provision should be made to ensure there are activities offered to meet the needs of all residents. Records of meal preferences should be available to the catering team, to ensure that preferred choices are available to everyone. The catering team should attend training on soft diets to provide guidance on variety, nutrition and presentation. 5. 6. OP26 OP33 All areas of the home must be free from offensive odours to ensure a clean and pleasant environment is maintained. The quality assurance system should include a report to residents/their representatives to show the action taken to improve the service based on their views and comments. Kilburn Care Centre DS0000058025.V362157.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kilburn Care Centre DS0000058025.V362157.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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