Inspection on 05/06/07 for Limefield Court Retirement Home

This inspection was carried out on 5th June 2007.

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

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

Other inspections for this house

Limefield Court Retirement Home 13/02/07

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Limefield Court Retirement Home 15 Limefield Road Bury Lancs BL9 5ET Lead Inspector Grace Tarney Unannounced Inspection 09:30 5th & 6th June 2007 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 Limefield Court Retirement Home DS0000068200.V335726.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. Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Limefield Court Retirement Home Address 15 Limefield Road Bury Lancs BL9 5ET 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) 0161 761 5164 0161 7629316 Lily Care Limited Pamela May Hall Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (31), Physical disability (1) of places Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 32 service users to include: *up to 31 service users in the category of OP (old age not falling within any other category). *up to 1 named service user in the category of PD (physical disability under the age of 65 years). 13th February 2007 Date of last inspection Brief Description of the Service: Limefield Court is a two-storey property that has been extended and converted and it is situated off a main road on the outskirts of Bury Town Centre. It is within easy reach of bus routes and is not too far from the motorway network. The home has 20 single bedrooms and 6 double bedrooms. All the bedrooms except for 2 singles have an en-suite toilet and hand-basin. The bedrooms on the first floor are reached either by stairs or a passenger lift. There is also a stair lift within the home. There is a large lounge and separate dining room on the ground floor and bathrooms and toilets on both floors. There is plenty of parking and large safe garden areas with seating for the residents The home is registered to care for up to 32 people who need residential personal care. Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was not told that this inspection was to take place although the home was aware that an inspection was due. This was because several weeks before the inspection, questionnaires (comment cards) were sent out to the residents and their relatives. The questionnaires that were sent out to the residents were called Have Your Say and they asked what people thought about their care and of the quality of the service provided. . 6 comment cards were returned, 2 from residents and 4 from relatives. What they felt about the care and services provided is written in different sections throughout this report. 1 Inspector visited on the first day and spent 8 hours at the home. During this time she looked at care records to ensure that the health and care needs of the residents were being met. She also looked at how many staff were provided on each shift to make sure the residents needs were being met, and also looked at how management recruit and train their staff. To make sure that the home and the equipment in it was safe, the Inspector looked at some of the maintenance and service records of the equipment within the home. How the home manages the residents’ spending money was also looked at. The Inspector then looked around the building at the bedrooms, bathrooms toilets and sitting areas to check if they were clean and well decorated. The Inspector also looked at the menus and looked at what the residents had for their lunch. A Pharmacy Inspector visited the home on the second day to look at the way that medicines are handled. In order to get further information about the home the Inspector also spent time speaking to 1 resident, 3 relatives, 3 care assistants, the cook and one of the owners of the home. A copy of the last inspection report is kept in the reception area. The provider informed the inspector that the weekly fees within the home ranged from £355.11 for a double room to £364.11 for a single room for people who have their care paid for by the local authority, plus a £6.00 “top up”. For privately funded residents the fees are £369.00. Additional charges are made for private chiropody, hairdressing and newspapers. This information was received on the 5th June 2007.. What the service does well: The manager makes sure that the home only cares for those people whose needs the staff can meet. The meals provided are varied, nutritious and plentiful. The Company is making sure that the staff are properly trained. Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 6 The home makes sure that they check people out properly and safely before offering them a job. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 7 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 Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 8 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 People are properly assessed before they are admitted to the home and this gives an assurance to everybody, that a person is only admitted if the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Although there have been no new admissions to the home since the last inspection, an inspection of 3 resident care files showed that before they were admitted to the home an assessment of their needs had been undertaken either by the manager or a senior member of staff. The home now uses a new assessment document that is very detailed and is able to show a clear picture of the residents’ needs and their capabilities. Standard 6 does not apply. The home does not provide Intermediate Care. Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 9 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. Quality in this outcome area is adequate. The care plans reflect the support needs of the residents however the unsafe medication system puts residents’ health and wellbeing at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: New care plans were in place for every resident in the home. It was evident that a lot of work had been done to get the care plans accurate and up to date. The care plans of 3 of the residents were looked at. They were very detailed and gave clear instruction and guidance on how the care needs of the residents were to be met when problems had been identified. The staff looked at whether or not there was any risk in relation to the residents developing pressure sores and also if they were at risk due to problems with their diet and fluid intake. These are called risk assessments. Risk assessments were in place for whether a resident was at risk of falling. They also looked at and they wrote down, how any resident was to be assisted with being moved around and by how many members of staff and what equipment, if any, was to be used to assist in safe moving and handling. Risk assessments were also in place for any general safety hazards such as if a resident had a kettle in their room or wanted a key for their bedroom door. Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 10 If a risk has been identified then an action plan to reduce or manage the risk was in place. The care plans were reviewed at least on a monthly basis. Inspection of the care files identified that the residents had access to health care professionals, such as dentists, opticians and chiropodists. Whilst the Inspector was in the home the falls coordinator was visiting. This is a person who assesses a resident who is prone to falls and looks at the best way to manage or reduce them. The following comments were made in the questionnaires received: • I am very satisfied. • They look after Mum to the best of their ability • General care is good. Following a discussion with some of the visiting relatives they made the following comments: • Well cared for • The staff are all very nice. The medication policy provided guidance for staff about the handling of medicines in the home. But, did not include information for staff about what they should do if they made a mistake when administering medication. This should be included in the policy to make sure the right action is taken if a mistake is made. All staff handling medication had completed certificated training and the acting manager had begun to carry out competency assessments, to make sure that staff administering medicines did so safely. It was of concern that the staff member administering the morning medicines had prepared medication for several residents at the same time. There were several medicines pots containing tablets and residents’ names on scrap paper, inside the medicines trolley. One pot containing a thick red liquid was unnamed. The administration records incorrectly showed these pre-prepared doses had been given. This poor practice increases the risk of mistakenly giving medicine to the wrong resident. Also, if medication was later refused, the precompleted records would need to be altered, making it less clear. Staff knew this was not good practice and said medicines were not normally administered in this way. There had been problems with the ordering of medication resulting in two residents being without any of their medication, one person for several days. Four other residents were without one of their medicines: two people for 3 and 6 days, and two people for the whole month (28 days). The acting manager said she now checked the prescriptions before they were dispensed and had spoken with the pharmacy to ensure medicines are delivered early enough for any ‘missing’ medicines to be delivered before they ‘run out’. Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 11 Comparison of the medication records with the medicines in stock showed that medicines were not always administered as prescribed: • No-one (3 people) prescribed once-weekly tablets was given them as prescribed – most doses were missed. • Eye drops were not given as prescribed to two residents. • One resident had missed almost half of her morning doses of medication over the last 28 days because she was in bed. The acting manger knew about this concern and was trying to make sure it didn’t happen again by introducing ‘reminder cards’. If the medicines are given later on, care will need to be taken to ensure enough time is left before the next dose is given. A new trolley and cupboard for storing controlled drugs had been purchased and medicines were safely locked away. The cupboard was over a radiator, so the temperature should be monitored to make sure it does not become too warm and affect the quality of the medicines inside it. The handing of controlled drugs was recorded in a proper register but the corresponding records of administration were not fully completed. One person prescribed and administered a controlled drug did not have a medication administration record for it. The residents looked clean and comfortable and were suitably dressed. The staff spoke to the residents in a quiet and respectful way. During the last inspection the Inspector was concerned about the call bell system in place in the home, because at times it did invade the privacy of the residents. This call bell system was in place when the new owner took over the home. This system is such that staff are able to listen in as well being able to speak to the residents in their own room. The owner showed the Inspector a copy of the letter he had sent out to seek the views of the residents and relatives in respect of the call bell system and showed their responses. The majority of replies were in favour of keeping the system in place. The owner said that he would keep peoples’ views under review. Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 12 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 good. The residents’ dietary needs are met and they have a choice in how they spend their day. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents’ routines of daily living and their social and religious interests were recorded in their care plans. One resident told the Inspector that he likes to stay in his room after lunch and that is what he does. The home does not employ an activities organiser and the Inspector was told that the carers undertake activities for the residents. Staff spoken to felt that now they had very little time to undertake activities. The Inspector was told that singers/entertainers are invited into the home on a regular basis. Also a Company that specialises in reminiscence and other activities goes into the home every month. The Inspector was also told the parties are held regularly for any special events such as Christmas, Easter and Birthdays. In answer to the question on the Have Your Say Questionnaire the following comments were made: Are there activities arranged by the home that you can take part in? • 1 resident said Sometimes and another resident said Never. Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 13 • Mum sleeps quite a lot but when they have games they always include her. Relatives confirmed that there were no unreasonable restrictions on visiting at the home and that visits could be conducted in the privacy of the resident’s room or quieter areas of the home. During the visit the Inspector saw 3 visitors sat in the lounge area. They all said that staff make them welcome. Staff told the inspector that the residents are encouraged to bring personal possessions into the home. Some of their bedrooms were personalised with pictures, photographs and ornaments. The residents have the main meal at lunchtime and the lighter meal in the evening. Inspection of the menus, a discussion with the cook and care staff showed that a 3-course meal is always offered. The residents also always have the choice of a main meal and sweet. The cook told the Inspector that she asks the residents before each meal what they would like to eat and this is then written down on the choice list. They also indicate on this list, which of the residents like a large, small or extra small portion. The Inspector did not have a meal with the residents but watched what they were having for their lunch. They had homemade soup, a choice of cheese and onion pie or a savoury mince, all with several vegetables and potatoes. Hot and cold drinks were available throughout the day. Comments from the Have Your Say Questionnaire were • Food provided is very good. • The food is good, no complaints at all. • The food is good. Any cultural or dietary needs, likes and dislikes were looked at when a resident is first admitted to the home. The care plan of 1 resident that was of African/Caribbean origin showed that she enjoyed different cultural foods from the local takeaway. The menu for the takeaway was kept in her care file so that the staff could order for her when she wanted a meal from there. Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 14 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. People know how to complain and staff have a good knowledge and understanding of what abuse is, thereby reducing the possible risk of harm to residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure was displayed and it is also included in the Service User Guide. It is easy to understand and gives an assurance that complaints will be responded to within 28 days. 2 complaints have been made to the CSCI since the last inspection of February 2007. They were about poor care practices and lack of adequate staffing. The Inspector looked at the issues during the inspection and found that at times there was insufficient staff on duty in the evening. The owner told the inspector that more staff were being recruited. There was no evidence to show that the care practices were poor. A comment from the Have Your Say Questionnaire was: • Ive never had to make a complaint. • I know how and who to complain to. The 3 relatives spoken to by the Inspector said that they had no complaints, although they did mention that the staff were always very busy. A copy of the Local Authorities Vulnerable Adults Procedure was in place and a discussion with the care staff showed that they were very aware of the procedure to follow in the event of any allegation of abuse. Training records were inspected and showed that training in the protection of vulnerable adults Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 15 had been undertaken and was an ongoing process. The Inspector was shown a training calendar that showed who had undertaken the training and who was scheduled to do it next. Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 16 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 21 22 24 25 & 26. Quality in this outcome area is good. The residents live in clean, suitably adapted and comfortable surroundings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The front door is kept locked for security reasons and an intercom system is in place. The corridors are wide with grab rails along the side to assist the residents with mobility problems. The radiators along the corridors remain unguarded. There is a large lounge and separate dining room on the ground floor. Both of these were clean, warm and suitably furnished. Apart from 2 bedrooms upstairs, each bedroom has an en-suite toilet and washbasin. There are two toilets off the lounge area. They had a lock on the door to ensure privacy and each had a call bell in place. There is a further toilet upstairs that is used by staff and by the residents who do not have an en-suite toilet. This toilet has an unguarded radiator. Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 17 Upstairs there is a room with a shower that is not suitable for disabled access. Downstairs there is a shower room and also a bathroom with an assisted sit in bath. All the bedrooms were looked at. They were all clean, warm and suitably furnished and had a lockable space for the residents to store anything that was important or valuable to them. All the bedroom doors had overriding safety locks but they were not the type of lock that had a key. This means that residents cannot lock their door when they leave their room. This was identified on the last inspection and the owner showed the Inspector the letters that he had sent out to residents or relatives, seeking their views on whether they wished to lock their door or not. There were mixed views on this and the owner said that he would keep the situation under review and provide locks with keys where people requested them. Most of the bedrooms had an unguarded radiator both in the bedroom and the adjoining en-suite toilet. Window restrainers were fitted to all first floor windows. In answer to the questions on the Have Your Say Questionnaire the following comments were made Is the home fresh and clean? 2 said always. The home was adequately heated. All the rooms were centrally heated with radiators in place, however they were not suitably protected to prevent any accidental burning. Following the last inspection the owner had undertaken a risk assessment for all the radiators in the home and identified that, at this time, there was no risk. The owner did state that the radiators would eventually be covered but this would be an ongoing process and they would be fitted according to the risk each radiator presented. The home was clean and free from odours. Hand washing facilities were in place in bedrooms, bathrooms and toilets. In addition, antibacterial hand cleaning gel for general use was mounted on walls throughout the home. Disposable gloves and coloured aprons were provided for staff use. The laundry area was clean, well equipped and looked well organised. Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 18 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 adequate. Although staff are suitably trained and safely recruited, at times there is insufficient staff on duty to meet the needs of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of the duty rotas, observation by the Inspector and a discussion with staff, relatives and a resident plus comments from the questionnaires showed that the home, at times was working with the absolute minimum amount of staff and at times was not staffed sufficiently. Between the hours of 8am to 3pm the rota shows at times that there are 4 carers on plus the manager working 8 to 4pm or 5pm. Sometimes the manager works an evening shift. Between the hours of 3pm to 9.30pm there are usually only 3 care staff on duty. 2 care staff are on duty throughout the night. A discussion with the owner showed that he was aiming for 4 care staff for the evening shift. The Inspector was informed that he was in the process of recruiting new staff. A resident told the Inspector that there was always a long wait when a request was made to go to the toilet or to go to bed. In answer to the questions on the Have Your Say Questionnaire and the relative comment card the following comments were made: Are the staff available when you need them? • Usually. • Yes they are good. Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 19 How do you think the care home can improve? • Need more staff for general care. Of the 13 care staff employed 8 have their NVQ 2 or above in care. This is a percentage of 62 and therefore the home has met the Standard. The catering staff are also undertaking their NVQ in catering. The personnel files of 2 staff members were inspected. These were in order as they had been properly and safely employed. They had a completed application form, 2 professional references, an enhanced criminal records disclosure (CRB) or POVA 1st check and a health status declaration. A detailed induction-training programme was in place and the Inspector was given a detailed training plan that shows what training has been undertaken by the staff, what is outstanding and when it has been scheduled. . The Inspector saw that the home has signed up with Bury Partnership in relation to the Skills for Care Training. The staff certificates of training or achievement are kept in the individual staff files. Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 20 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. Most practices within the home safeguard the welfare of the residents, staff and visitors This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has recently appointed a new manager who is in the process of being registered with the CSCI. She has 11 years experience within the care home environment, 2 years as home manager and 9 yrs as a senior care assistant. She has not yet completed the Registered Managers Award The home has developed its own quality assurance system to check on the quality of the care and services provided. The owner has started to have relative/resident meetings, the first one being held in January 2007. The Inspector saw the minutes of this meeting. Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 21 Staff meetings are held monthly and the minutes were displayed on the office notice board. Staff and residents confirmed that the owner visits the home every evening to make spot checks, discuss any problems, check on supplies and talk to staff, residents and visitors. The Inspector saw copies of the questionnaires that are also sent out to residents asking for their views about the care and facilities provided by the home. The Inspector also saw a record of the regular checks that the manager undertakes on the bedrooms, the fire log and the care plans. The system in place for the management of the residents’ spending money was good. The Inspector was told that their families generally undertake the management of residents’ finances. The home had satisfactory accounting systems in place. Receipts were kept for all financial dealings. The home had a detailed Health & Safety Policy. Regular weekly checking and testing of fire detection system, fire exits and emergency lights was undertaken and documented. Information obtained from the Annual Quality Assurance Assessment sent in by the home and from random checking of servicing records showed that the homes fixtures, fitting and equipment are properly maintained and regularly serviced. The concerns identified during the last inspection in relation to the unprotected radiators remain, although the owner told the Inspector that radiator covers would be fitted according to the risk each radiator presented. Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 22 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 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x 3 x x 3 2 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 2 Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement Medication must be administered as prescribed (recorded if refused) to protect the health and wellbeing of people living in the home. When medication is administered it must be clearly and accurately recorded, to ensure that people receive the correct levels of medication. The way that medicines are administered should be reviewed in accordance with RPSGB guidelines to ensure they are always administered in the safest way. To protect the health and safety of the residents, the system of undertaking risk assessments on the unguarded radiators must continue and appropriate action taken to reduce any risk identified. The home must be staffed to meet the individual needs of the residents. Timescale for action 07/06/07 2. OP9 13(2) 07/06/07 3. OP9 13(2) 09/07/07 4 OP25 13(4)(a) 06/06/07 5. OP27 18(1)(a) 06/06/07 Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP9 OP12 OP24 Good Practice Recommendations The medication policy and procedures should be reviewed and expend to include a procedure for handling medication errors Consideration should be given to employing an activities person. People should be asked on admission if they would like a lock with a key for their bedroom door. Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Limefield Court Retirement Home DS0000068200.V335726.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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