Care Home: Kirk House Nursing Home

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What the care home does well People choosing to live in this home can feel sure the home would thoroughly assess their needs before they move in. People`s needs are assessed and planned for, staff are aware of what they need to do and people who live here told us they were very happy with the care they receive. They said "it is wonderful here", "they help me as I need, they know what I want". There is a wide variety of activity for people to take part in both in and outside of the home. People are encouraged to personalise their rooms to make them feel more like home to them. Meals are well planned and a variety of dietary needs can be catered for. People told us "the food here is always lovely", "they always make something I like and there is always a good choice available".The home is clean and offers a pleasant and relaxing place for people to live. The people who live here told us they were very happy with the home and were also complementary about the staff. "The staff are pleasant and happy and always chatty". What has improved since the last inspection? During our last visit we made requirements for the home to take action on. It was pleasing to see that this action has been completed. We saw that recruitment practices have been improved. The home is now making sure that the required safety checks against the Protection of Vulnerable Adults list (PoVA) and Criminal Records Bureau disclosures (CRB) are completed before new staff start working in the home. This will make sure that reasonable steps have been taken to prevent unsuitable people from working with vulnerable adults. Medication practices have been improved and as a result people can feel confident their medication will be given to them as the doctor prescribed it. The fire evacuation plan has now been completed and each person has their own personal evacuation plan. This will help assist the fire service in the event of fire breaking out. Since our last visit the extension to the home has been completed although the first floor is still not in use at this time. The new extension provides new bedrooms with en suite facilities. They are all pleasantly decorated. CARE HOMES FOR OLDER PEOPLE Kirk House Nursing Home Balance Street Uttoxeter Staffordshire ST14 8JE Lead Inspector Mandy Beck Key Unannounced Inspection 28th August 2008 09:00 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 Kirk House Nursing Home DS0000022345.V370518.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. Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kirk House Nursing Home Address Balance Street Uttoxeter Staffordshire ST14 8JE 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) 01889 562628 01889 564976 kirk.house@tesco.net Uttoxeter & District Old People`s Housing Society Limited Amanda Anne Clayton Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35), Physical disability (35) of places Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with nursing (Code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category (OP) 35 2. Physical Disability (PD) 35 The maximum number of service users to be accommodated is 35. Date of last inspection 8th October 2007 Brief Description of the Service: Kirk House Care home provides personal and nursing care to a maximum of thirty five older people over the age of sixty years. It is owned and operated by the Uttoxeter and District Old People’s Housing Society Limited, which is a voluntary organisation. Kirk House offers a variety of accommodation. There are five double bedrooms in which screening is provided to afford peoples’ privacy. The rest of the bedrooms are single occupancy, the majority of these rooms also have en suite facilities. There are three bathrooms and two shower rooms for people to use. There are three lounges and one dining room at present but a further lounge and dining room will be available once the new extension is completely opened. Visitors are encouraged to make use of the kitchenettes to make drinks when they visit. The home also provides a hairdressing salon for people to access. There are gardens to the rear of the home and there are also plenty of car parking spaces available. The home is situated very near to the town centre and is on the local bus route. The home is a short 10 minute walk from the town centre and local amenities. The fees for this home are currently being updated in the Service User Guide. Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 5 Readers of this report are asked to contact the home directly for this information. A copy of the most recent inspection report is available from the office on request. Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that people who use this service experience good quality outcomes. We looked at all the information that we have received, or asked for, since the last key inspection. This included: • The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. • Information we have about how the service has managed any complaints. • What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. • The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. • Relevant information from other organisations. • We also spent time talking to the people who use the service and to the staff who support them. We looked at the care of three people who use this service in depth. This is part of our case tracking process and helps us makes judgements about the home’s abilities to meet people’s needs What the service does well: People choosing to live in this home can feel sure the home would thoroughly assess their needs before they move in. People’s needs are assessed and planned for, staff are aware of what they need to do and people who live here told us they were very happy with the care they receive. They said “it is wonderful here”, “they help me as I need, they know what I want”. There is a wide variety of activity for people to take part in both in and outside of the home. People are encouraged to personalise their rooms to make them feel more like home to them. Meals are well planned and a variety of dietary needs can be catered for. People told us “the food here is always lovely”, “they always make something I like and there is always a good choice available”. Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 7 The home is clean and offers a pleasant and relaxing place for people to live. The people who live here told us they were very happy with the home and were also complementary about the staff. “The staff are pleasant and happy and always chatty”. What has improved since the last inspection? What they could do better: We have made some recommendations to add to the security of medication storage and improving recording on the Medication Administration Record (MAR). These recommendations will provide additional safeguards for the people living here. The home does make an assessment of risk for each person but we have recommended that individual bed rail risk assessments are introduced. The current risk assessments are not detailed enough to cover all aspects of risk associated with bed rail usage. Please contact the provider for advice of actions taken in response to this Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 8 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. Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 9 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 Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 10 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): 1,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People moving into this home can feel confident their needs will be assessed in full before they move in. Those people who use the intermediate care services will be encouraged to be as independent as possible in readiness for their return home. EVIDENCE: We looked at three people’s care records as part of our case tracking process. We found that each person had a full assessment of their needs before they moved into the home. This means that as soon as people move into the home staff are aware of their care needs and how to meet them. This home also offers intermediate care facilities. This means that people can use the service on a short-term basis to either prevent an admission to hospital or to support them in regaining their independence following a hospital Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 11 stay. We had the opportunity to speak to a member of the intermediate care team during this inspection they were very complimentary about the home and the care they provide. We were told “they give very good excellent care, we have no concerns and complete confidence in the home meeting people’s needs”. People are supported to be as independent as they can be and whilst using this service will be visited by the enablement team who will work with the home to make sure that people’s independence is being nurtured. Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 12 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): 7,8,9,10,11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s healthcare needs are being met. Staff are aware of individual care preferences and people can be assured they will be treated with respect and dignity at all times. EVIDENCE: The home uses a computerised system of care planning and risk assessment. The system contains each person’s individual care plans and related documents. We looked at the plans for three people in depth during this inspection. We found that care needs had been planned for and were kept under regular review. Risk assessments are in place that looks at people’s risk of developing pressure sores, moving and handling and malnutrition. People also have an individual risk assessment for other aspects of their care that covered issues such as bed rail risk assessment and the use of lapbelts on wheelchairs. We have recommended that these risk assessments be reviewed because they are not detailed enough. A detailed bed rail risk assessment Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 13 would ensure that all areas of potential risk are assessed and identified with bed rail use. We spoke to care staff about the care of people we had case tracked, they were able to tell us in detail about each person and their preferences. It was pleasing to see that the information staff gave us was mirrored in the care plans we had seen. This shows us that staff are kept informed of people’s needs and as a result people living here will be getting the care they want. We also saw evidence that people have access to medical services, as they need them. Community specialists such as physiotherapists, occupational therapists and community mental health nurses support the home. People also have access to chiropodists, dentists and opticians. We were told “I feel under the weather the staff always call the doctor to make sure I’m ok”. Medication systems are good. Only trained nurses administer medicines in this home. Since our last visit the home has made improvements to this system by making sure that all people who need paracetamol now have it individually prescribed for them rather than from a stock. The home makes sure that it records the temperature of the drugs fridge on a daily basis and that it is not to hot or cold to store medicines. We have also recommended the staff begin to record the temperature of the treatment room for the same reasons. Controlled drugs are stored safely and securely, although the drugs cupboard was rather full. The home may wish to consider supplying a larger cupboard for this purpose. All medicines we checked balanced and appropriate records were kept. We noticed that the key to the treatment room was on a hook outside the room. This meant that the room was freely accessible to people. We have recommended the key be removed in order to add the security of medication storage. The manager removed this key immediately and will provide alternate arrangements for storage of equipment that staff need access to. We have also recommended that a lock be added to the cupboards in the treatment room where surplus medications are stored. Throughout this inspection we have seen that people are treated with respect and staff take time to make sure people’s dignity is not comprised. We saw staff talking to people politely, chatting and making jokes with them. We noticed that staff knock the door prior to entering people’s bedrooms and toilet area. The home has very good arrangements in place for end of life care for people. The home uses the Liverpool Care Pathway, this means that people who need end of life care are supported in the way they would wish and are kept comfortable and pain free. The home is also supported by the palliative care Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 14 services and the doctor. There were no people using this pathway at the time of this inspection. Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 15 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): 12,13,14,15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People are supported to maintain active links with the local community and with their families. Meals are of a good quality and enjoyed by people living here. EVIDENCE: The activities co-ordinator continues to improve the provision of activities and stimuli for people living here. She has completed a life history for each person and has spent time getting to know them and gleaning important information from them and their families. From this she has been able to develop an activities plan. Daily activities are arranged which include reminiscence sessions, physical exercises and quizzes. The activities co-ordinator will also do one to one activities, especially for those people with dementia. These include hand massage, story telling and colouring. A relative comes into the Home to help with arts and crafts. ‘Theme’ days are also arranged. Most of the people living here are able to take part in activities. Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 16 The two church visitors said that they visited the Home once a month to offer the residents communion and that it was better arranged since the employment of the activities co-ordinator. The Home has a fundraising committee who have raised funds for various activities and events and are currently raising money for a mini bus. The Home is part of the local community and encourages community participation. The Home is situated within a few minutes walk of the town centre and staff take the residents. A bingo night is held every two months, to which families and members of the local area are invited. The day before the inspection some of the residents went to the local Roman Catholic Church. A member of the local Methodist Church also comes into the Home. None of the present residents have alternative religions or faiths, although some are nonpractising and therefore they do not have to attend Christian services. We had the opportunity to talk to relatives during this inspection , they told us “the home supports people very well, my mother was very ill and they have bought her back to health”, “ we plan lots of activities to but the weather hasn’t helped us this year we had planned a garden party” The hairdresser visits two days a week. Relatives are welcomed into the Home and the Service Users Guide says that they can visit at any time. There are separate visitors’ facilities including two small kitchens for making drinks. Following discussions with the residents the relatives can now visit with them in the communal lounges. We had the opportunity to eat a meal with people. They told us “the food is always very nice”, “there are choices each mealtime”. The food we tried was tasty and it was a good-sized portion. The choice on the day of this inspection was either fish, sausage or egg with chips and vegetables. Dessert choices were strawberry mousse, pears and cream or lemon sponge and custard. There are three cooks employed at Kirk House working a variety of shifts. People are offered four meals a day; breakfast, lunch, high tea and supper. Choices are available at all meal times and people we spoke to said that they could have an alternative to the menu. The Home also caters for people requiring a soft diet and diabetes. Some of the people living in this home need help to eat. This was seen to be done in a sensitive manner that did not draw attention to them. People’s nutritional needs are recorded on the care records and they are regularly weighed. Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 17 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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can feel assured that their concerns will be listened to and acted upon. Staff have received training so people can feel confident they will be protected from harm or abuse in this home. EVIDENCE: The home has a complaints policy, which is detailed in the Service User Guide and Statement of Purpose. Since our last visit the home has not received any complaints. We, the commission have not received any complaints or concerns about this service. The home does have systems in place to enable them to respond promptly to any concerns or complaints that people may have. One person told us “I never have a complaints but there has been an occasion when I have grumbled about small things and this was dealt with quickly and to everyone’s satisfaction”. The home takes steps to make sure that all staff are aware of their role and responsibility in protecting vulnerable adults from harm or abuse. Each member of staff is trained as part of their induction and updates are arranged regularly after this. We spoke to staff during the inspection who were able to tell us the different types of abuse, who they would report this too and understood their role in keeping people safe. Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 18 We have recommended that risk assessments for bed rails and lap belts be revised because the current arrangements lack the detail we would expect to see in a risk assessment when using this type of restraint. Since our last visit the home has taken steps to improve the recruitment practices. It is now making sure that people do not begin employment in the home without the required safety checks in place. This includes a check against the Protection of Vulnerable Adults list (PoVA) and Criminal Records Bureau disclosure (CRB). These checks will help prevent unsuitable people from working with vulnerable adults. Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 19 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): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean and offers a pleasant place for people to live in. EVIDENCE: We did not look around the entire home but did see most of it during this visit. The home is clean and pleasant. We saw that people take the opportunity to personalise their own rooms so that they feel more like home to them. The biggest change since our last visit has been the completion of the extension which will eventually offer a further nine extra bedrooms. At present the first floor is still not in use and needs further work. Downstairs however is pleasantly decorated; the rooms are furnished to a high standard and offer a relaxing place for people to live. Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 20 Other areas of the home are also due to be redecorated in the very near future. This includes the two lounges at the front of the home. They are in need of redecoration and will be welcomed by the people using these rooms. The home has satisfactory arrangements in place for infection control. There is liquid soap and paper towels in toilets and bathrooms. Staff have access to gloves and aprons to protect them and prevent infection from spreading when helping people with personal care. Laundry facilities are located on site and there are sufficient washing machines and dryers for the home. Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are recruited safely and have appropriate training that enables them to carry out their duties. People can be assured there will be sufficient staff on duty to meet their needs. EVIDENCE: At the time of this inspection there were thirty people living in the home. There is always one Registered General Nurse on duty and in the morning there are six care workers, five in the afternoon and two at night. The manager, administrator, activities co-ordinator, laundry, maintenance, cleaning and catering staff are supplementary to this. Recently the manager has been included in the care numbers due to low staffing levels. The manager told us that staffing levels are kept under review and will be review again when the new extension is fully opened and the home is at full capacity. (thirty five people will live here when this happens). The home supports it staff in completing training such as their National Vocational Qualification (NVQ) level 2 and 3, at present over 68 of the care staff have achieved this. There are plans to enrol new members of staff onto this training once their induction pathway is completed. We looked at the recruitment files for four new staff. We saw that improvements have been made since our last visit. As we previously Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 22 mentioned staff are now in receipt of the required safety checks before they begin their employment with the home. Files we saw showed that the home is obtained two written references, CRB and PoVA checks for all staff. The home could further add to these safeguards by making sure a risk assessment is completed for those staff who begin work with only a PoVAfirst check in place whilst they are waiting for a satisfactory CRB. Staff in this position should be supervised until their CRB is returned. We spoke to staff about their induction to the home; they told us they were supported throughout this time. They had training that included Protection of Vulnerable Adults, health and safety, fire training and first aid. The homes induction programme meets the Skills for Care induction standards and offers people a good introduction to social care. Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed well and run in the best interests of the people who are living there. EVIDENCE: There has been no change in management since our last visit. The home contonues to be managed well and people retain the confidence in the home manager Amanda Clayton. The Home has a Quality Assurance system in place. Monthly meetings are held with relatives and volunteers within the ‘Friends of Kirk House Social and Welfare of Service Users’ group. A member of the Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 24 committee is also involved in the ‘Friends of Kirk House’ so that the residents and relatives have access to them in an informal manner. Members of the committee visit the home on a regular basis to talk to the residents, relatives and visitors. We had an opportunity to talk to a member of the committee during this inspection who told us that they were pleased with the progress the home is making and believe the committee is offering a home to people that they can be proud of. Questionnaires are sent out on a six monthly basis to people living in the home, this gives them a further opportunity to be able to express their views and opinions. Relatives/next of kin are asked to give their opinions. All questionnaires are collated and an action plan on improvements is formulated and action carried out if appropriate. The home is able to keep people’s money safe for them. There are secure facilities for them to do this. People are encouraged to manage their own money but most prefer to leave their money with the home for ‘safe keeping’. Those people who do wish to keep their own money with them have a lockable facility in their rooms to keep it safe. We checked the money and balanced of three people living in the home. All were correct and the home does provide records of expenditure. We have recommended however that receipts for transactions would provide a further safeguard for people. The health and safety of people is promoted throughout the home. Safety checks and certificates were not seen during this inspection but were seen as part of the home’s registration visit in May 2008 when the new extension was registered with us. The home has also told us in the Annual Quality Assurance Assessment (AQAA) that the home’s safety certificates are up to date. We spoke to staff who confirmed that they have had training in health and safety, fire safety, first aid and infection control. The manager also told us that she is currently trying to arrange food hygiene training for all staff. Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 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 Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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 4 Refer to Standard OP7 OP9 OP9 OP18 Good Practice Recommendations People should have more detailed risk assessments for bed rails and lapbelts. This will provide a further safeguard for people who need this equipment. The temperature of the treatment room should be recorded on a daily basis to make sure that medication is being stored as manufacturers recommend. Locks should be provided to the medication storage cupboards in the treatment room to improve medication safety. A risk assessment should be in place for those people who begin work with only a PoVAfirst check in place, until the CRB is returned this to make sure that people using the service are well protected. Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Kirk House Nursing Home DS0000022345.V370518.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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