Inspection on 10/07/06 for Reardon Court

This inspection was carried out on 10th July 2006.

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

Reardon Court 07/03/06

Reardon Court 26/09/05

Reardon Court 12/01/05

Reardon Court 14/07/04

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

CARE HOMES FOR OLDER PEOPLE Reardon Court Cosgrove Close London N21 3BH Lead Inspector Wendy Heal Key Unannounced Inspection 10th July 2006 11:00 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 Reardon Court DS0000033461.V301098.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. Reardon Court DS0000033461.V301098.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Reardon Court Address Cosgrove Close London N21 3BH 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) 020 8447 9980 020 8350 4802 London Borough of Enfield Mr Mark Whitbread Care Home 36 Category(ies) of Dementia - over 65 years of age (36) registration, with number of places Reardon Court DS0000033461.V301098.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Nine of the 36 places are provided specifically for Intermediate Care in a separate dedicated flat. Nine of the 36 places are provided specifically for short-term respite care in a separate dedicated flat. One service user specified to the Commission and who is under the age of 65 may continue to be accommodated in the home until discharged. The Commission for Social Care Inspection must be informed as soon as that service user is discharged. The provider must undertake a programme of measures that will achieve full compliance with the National Minimum Standards for Older PeopleStandards 19-26 - Environment, or those equivalent standards that may be published at the time, as required by Regulation 23(1)(a); 23(2)(a to p); 23(4)(c) and Regulation 16(2)(c)(g)(j)(k) - by 1st October 2004. In order to promote the health and safety needs of service users living in Reardon Court. The provider must ensure that the home complies with all requirements contained in the relevant Health and Safety legislation and further must undertake a programme of measures that will achieve full compliance with National Minimum Standards for Older People - Standard 38 - Safe Working Practices, or those equivalent Standards that may be published at the time, as required by Regulation 23(1)(a); 23(2)(a to p); 23(4)(c) and Regulation 16(2)(c)(g)(j). One specified service user who is under 65 years of age may be accommodated in the home for respite care. The home must advise the registering authority at such times as the specified service user attains 65 years of age or vacates the home. One specified service user who is under 65 years of age may be admitted to the intermediate care flat for rehabilitation. The home must advise the registering authority at such time as the specified service user vacates the home. 4. 5. 6. 7. Reardon Court DS0000033461.V301098.R01.S.doc Version 5.2 Page 5 Date of last inspection 7th March 2006 Brief Description of the Service: Reardon Court is a purpose built care home providing a service to elderly people. The service is divided into four flats or units, each providing a specific service. There are two units, 11 and 12, for permanent service users who have a diagnosis of dementia. Unit 29 provides intermediate/rehabilitation care service and unit 30 provides respite care. Reardon Court also provides a range of other services such as a day centre, sheltered accommodation and an outreach service. Reardon Court is situated in a quiet, secluded residential area close to open land, transport links and the shops and services of Winchmore Hill. The Purpose and Function Document and Reardon Courts inspection report are available on the homes notice board. Reardon Courts fees are ^602.00 per week. Reardon Court DS0000033461.V301098.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took place as part of the routine inspection programme. Compliance was checked against key standards and took approximately 8 hours. The inspector undertook a tour of the building and spoke with service users and members of the staff team. The inspector gained further information by an inspection of the documentation kept in the home including care plans and health and safety documentation. At the time of the inspection the registered manager was on his day off and the deputy manager was on leave. Members of the senior management team assisted the inspector with the inspection. The inspector would like to thank the service users present during the inspection, senior managers and staff who were all very helpful. What the service does well: What has improved since the last inspection? Food is being stored appropriately in all of the flats, which is beneficial to the health of service users. The kitchens in flats 11 and 12 have been updated providing a nicer home for service users to live. The showers in flats 29 and 30 have been refurbished. The flooring in all of the showers in all of the flats has been replaced with non-slip flooring, which ensures the health and safety needs of service users are met. The blinds in the bedrooms in flat 29 have been replaced, which personalises service users’ bedrooms further. Medication is being stored at appropriate temperatures, which means it will not deteriorate. Supervision is taking place on a regular basis in all of the flats, which ensures a consistent approach can be undertaken by staff to meet service users’ needs. The action taken from the quality assurance exercise has been included in the service users’ newsletter, which shows that service users’ views are taken seriously. Reardon Court DS0000033461.V301098.R01.S.doc Version 5.2 Page 7 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. Reardon Court DS0000033461.V301098.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 Reardon Court DS0000033461.V301098.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5,6 The quality in this outcome area is good. The judgement has been made from evidence gathered both during and before the visit to the service. Service users are given the information they need to make an informed choice about whether the service is suitable for them and their needs. Service users have an individual contract of terms and conditions, which means they know what the expectations are for them and vice versa. Service users and their relatives are able to visit the home to assess the quality, facilities and suitability of the home in relation to their individual needs. Service users referred for intermediate care are helped to maximise their independence to assist them to return home. EVIDENCE: There have been a number of new admissions to the home in flats 11 and 12, since the last inspection. Inspection of the files indicated that assessments had been sent to the home which had been completed by the relevant care professionals, and that the home completes it’s own initial assessment on Reardon Court DS0000033461.V301098.R01.S.doc Version 5.2 Page 10 individual service users, which ensures that the service users’ needs can be met. The inspector also noted evidence of visits by the social worker to see how a service user had settled in, which assists the service user in ensuring their individual needs are met. The home has an up-to-date Purpose and Function Document, which reflects the current arrangements of the service and therefore provides relevant information to service users. The home has a service user guide. The home’s Service User Agreement clearly specifies the terms and conditions of the home including areas like the opportunity to furnish your own room with personal items which assists service users to feel more at home. It also includes the additional services to be paid for above those included in the fees, service users’ rights, the conditions in which the service could not continue to care for a service user, including information in relation to complaints and details of the notice period. The Service User Agreement ensures that there are clear expectations for service users and for the service. Service users assessed and referred solely for intermediate care are helped to maximise their independence. The inspector examined evidence, which included clear referral information, assessments, which included cognitive assessments, and progress reports completed by the relevant professionals. The service users had clear identified goals, which would assist them to return home, were possible and maximise their independence. The inspector spoke with a number of service users and all said they were supported to settle in. One service user said, “the staff are brilliant and were very supportive when I moved in”. Reardon Court DS0000033461.V301098.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11, Quality in this outcome area is adequate. The judgement has been made from evidence gathered both during and before the visit to the service. Service users’ care plans are up-to date, which assists staff to consistently meet service users’ needs. Risk assessments must be updated to ensure the risks to service users are minimised. Service users are appropriately supported to meet their health care needs. Service users are not fully protected, as the recording of medication is not always completed effectively. Service users’ rights are respected and service users’ wishes are respected, as their wishes are recorded with regard to the action to be taken in the event of their death. EVIDENCE: Care plans were inspected in flats 11,12,29,and 30. The care plans were clear to read. The care plans evaluate all aspects of living in the home. The needs are identified as well as the aims to achieve by care intervention. The care plans are being evaluated on a regular basis. The care plan specifies the areas in which service users make decisions about their lives with assistance. Reardon Court DS0000033461.V301098.R01.S.doc Version 5.2 Page 12 The risk assessments to show potential risks for identified service users in flat 30 must to be reviewed and updated due to the service users’ changing needs. One service user has a history of falls and now her mobility needs have changed and this service user no longer administers her own medication, which has not been identified on the risk assessment. One service user’s records state he administers his own medication, but this is no longer the case, this service user can get unsteady on his feet and can become distressed when this happens therefore any risks to the service user or staff needs to be identified in the risk assessment. A requirement has been made in relation to this. The service users’ care programmes also need to be updated and the manager of the respite unit is in the process of ensuring that all care programmes are reviewed and updated. Evidence was seen that service users are supported to meet their health needs including attending appointments with relevant health care professionals. Service users’ files inspected provided evidence that service users were registered with a General Practioner. The files identified a range of appointments, which included the chiropodist, optician, and visits by the district nurse who also visited a service user in flat 30, whilst the inspector was completing the inspection. The service users benefit from planned visits by a hairdresser who visits the home. Service users confirmed they received the support they required in relation to their personal care. One service user said, “they support you in a murmur nothing is to much trouble”. Service users were happy with the laundry service provided which assists them to maintain their personal appearance. On the day of the inspection the inspector observed that all service users were well dressed which assists them to further develop their self-image. The medication in the respite unit was inspected. The medication bottles were clearly labelled which ensures the health and safety of service users. The respite unit now has a fridge for the storage of medication, which was being stored at appropriate temperatures to prevent the deterioration of medication, which ensures that medication is stored in a professional manner and safeguards the health and safety of service users. The medication administration records in flats 29 and 30 were inspected and not all medication that had been administered had been clearly signed for and recorded on the MAR sheets in both of these flats, which does not safeguard the service users’ health and safety. A requirement has been made in relation to this. Service users felt that they were treated with respect; service users have a key available for their bedroom if they wish to use it. On the day of the inspection Reardon Court DS0000033461.V301098.R01.S.doc Version 5.2 Page 13 the inspector observed the interaction with service users and staff, which was appropriate. The service users’ wishes in the event of their death are recorded in their files, which ensures that their individual wishes are respected. Reardon Court DS0000033461.V301098.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. The judgement has been made from evidence gathered both during and before the visit to the service. The service user’s lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational needs which improves their quality of life. Service users maintain contact with family members and friends, which benefits their emotional wellbeing. Service users exercise choice and control over their lives, which aids their self-esteem. Service users enjoy nutritious healthy meals, which ensures their dietary needs are met. EVIDENCE: On the day of the inspection, six-service users’ case files were inspected in total in flats 11 and 12; three service users’ files were inspected in flat 29 and four in flat 30. The inspector saw evidence that indicated that service users’ expectations and preferences along with their social, cultural, religious and recreational needs are being met which enriches service users’ quality of life. The inspector observed that the activities taking place in the individual flats were based on the individual service users’ interests including listening to music, playing and seeking enjoyment and pleasure from caring for a new kitten and spending time in a well maintained garden. One service user was very involved in reading, which is an activity identified in her care plan and her Reardon Court DS0000033461.V301098.R01.S.doc Version 5.2 Page 15 individual needs are further met by regular visits from a staff member from the local library. Service users living in the residential flats are able to access the day services, which offer a wide range of activities, games, quizzes and creative activities. On the day of the inspection a number of service users from the day centre had gone to visit Woburn Safari Park. Service users’ religious preferences are identified on their care plan, which ensures their rights are respected. The inspector observed and had a conversation with a service user who was being visited by a relative who regularly joins her for a meal, and it was evident on the day of the inspection that this family contact is encouraged and maintained by the staff at the home which benefits service users’ emotional wellbeing. The inspector saw evidence that service users are helped to exercise choice and control over their lives. Service users are provided with choices ranging from the activities they attend, how support is offered in relation to personal care, contact arrangements and having a choice with regard to the food they wish to eat which all benefit the development of service users’ self-esteem and ensures they feel valued. On the day of the inspection the kitchens in all of the individual flats were clean and tidy, which benefits the health and safety of service users and staff. The menu of food available was wholesome and nutritious and incorporated fresh fruit and vegetables, which ensures the service users’ dietary needs are being met. The contents of the fridge were inspected and all food was identified as being within its use by date and had been stored correctly, which ensures service users’ health is safeguarded. Service users benefit from a mixed staff team who bring a range of different ideas to the home in terms of food and food preparation. This benefits service users as they have access to different types of food than they may otherwise experience. One service user who had spent his working life in the food industry said, “The food is very good and met his needs”. Service users’ cultural needs are being catered for; it was observed that those service users who had identified preferences in their care plan for example yam and rice had this available to them on the day of the inspection. Another service user who eats very little and did not eat her meal had an alternative meal provided; to make sure her needs were met. Service users are provided with gluten free diets. The inspector observed a number of service users that are identified as diabetic in their care plan who were offered appropriate alternatives in terms of food to ensure their individual needs were met. The inspector joined the service users for their meal, which was of a high standard and well presented. All those service users spoken with commented Reardon Court DS0000033461.V301098.R01.S.doc Version 5.2 Page 16 on how much they enjoyed the food available, which makes mealtimes enjoyable for service users. Reardon Court DS0000033461.V301098.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. The judgement has been made from evidence gathered both during and before the visit to the service. Service users, relatives and friends can be confident their views are listened to and acted upon since the recording of complaints and action taken is adequate. Service users are protected by trained staff that have an adequate understanding of how to protect service users from abuse. EVIDENCE: The home has an adequate complaints procedure, which enables service users to have the information they require to enable them to make a complaint if they need to. At the time of the inspection the inspector looked at the complaints file. There were a number of complaints since the last inspection, which had been appropriately responded to by the manager and where necessary by the service manager. The timescale could be identified in relation to when the necessary action had been taken and all documentation was signed and dated, which reassures service users, and their friends and relatives that complaints are listened to and taken seriously. Staff have attended Adult Abuse and Protection of Vulnerable Adults Training, and during a discussion with staff it was evident that staff were knowledgeable with regard to the reporting procedures, which assists service users to be protected from abuse. Reardon Court DS0000033461.V301098.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25,26 Quality in this outcome area is adequate. The judgement has been made from evidence gathered both during and before the visit to the service. Service users live in a safe, adequately maintained environment with safe, comfortable, indoor and outdoor facilities, which make Reardon Court a pleasant place to live. Service users have a sufficient number of bathrooms and toilets but the bathrooms require improvements to be made to ensure service users needs are fully met. Service users have their own bedrooms, which, are personal and suit their needs. Reardon Court is clean and hygienic which protects service users’ health and safety. EVIDENCE: The inspector completed a tour of the four separate flats. Since the previous inspection a number of environmental improvements have taken place, which included replacement of the tiled floors in the bathrooms and showers with a Reardon Court DS0000033461.V301098.R01.S.doc Version 5.2 Page 19 non-slip alternative, which ensures service users’ health and safety needs are met. The showers in flat 29 and 30 have been refurbished which will mean that the mobility needs of service users and their individual personal care can be better met. The kitchens in flat 11 and 12 have been fully refurbished, with new flooring base units and sinks, which provide a nicer environment for service users to live and for the staff to work. The replacement of the blinds in flat 29 with new curtains assists to maintain service users’ privacy and service users’ personal items make service users’ bedrooms look and feel homely. One service user said, “The bedroom is very comfortable and clean.” All of the individual flats were clean tidy and free from offensive odours, which ensures the health, safety and wellbeing of service users. The bathrooms in flats 11 and 30 require refurbishment and costings have been prepared. The modernisation of the laundry rooms in flats 11 and 12 has not yet taken place but has been proposed for 2007. This work is listed as a restated requirement in this inspection report. Reardon Court has a well - maintained garden for service users to enjoy. Reardon Court DS0000033461.V301098.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,30. Quality in this outcome area is good. The judgement has been made from evidence gathered during and before the visit to the service. The service has adequate numbers of staff on duty to meet the needs of service users. Staff are adequately trained and competent to do their jobs. EVIDENCE: During the inspection the inspector looked at the rota and the number of staff on duty during the visits to the flats, which identified that there were adequate numbers of care and ancillary staff available in each of the flats to meet the needs of the service users. There are adequate numbers of staff that have completed their NVQ2 and 3 or are completing their NVQ level 2 and 3. Staff are supported to receive the necessary induction and ongoing training. The inspector spoke with staff and all were happy working at Reardon Court. Two staff said, that they “enjoyed working at Reardon Court it had a very friendly atmosphere”. Reardon Court DS0000033461.V301098.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36,38 Quality in this outcome area is adequate. The judgement has been made from evidence gathered both before and during the visit to the service. The home is well managed by a stable and competent management team. The views of service users and relatives are sought through a quality assurance system. Staff are appropriately supervised which ensures all staff undertake a consistent professional approach. The health safety and welfare of service users and staff is promoted but magnetic door closures must be fitted to ensure service users are fully protected in the event of a fire-taking place. EVIDENCE: Reardon Court DS0000033461.V301098.R01.S.doc Version 5.2 Page 22 The service has an experienced registered manager and is supported by a skilled senior management team, which means that the service is managed to a consistently high standard. The senior managers have clear lines of accountability and areas of responsibility, which assists them to be effective managers. The quality assurance audit was undertaken in 2005. The manager confirmed to the inspector during a follow–up telephone call, that the actions taken in relation to the comments made in the questionnaires have been responded to in the organisations newsletter. He has agreed to forward this to the commission. The quality assurance questionnaire is currently being undertaken by the manager for 2006, which ensures that service users’ views are listened to and acted upon. Staff supervision records were inspected and all staff were receiving regular supervision, which means that a professional and consistent approach is maintained to ensure service users’ needs are met. Regular staff meetings are taking place and the minutes were available for inspection, which means that there are procedures in place to aid good communication. The records of weekly fire alarm tests, emergency lighting and fire drills were inspected and found to be in order and the fire officer last visited on 17/10/05. The fire officer has advised that the kitchen doors in flats 11 and 12 are replaced and costings have been requested for this task to be completed. The power supply in the linen cupboard has been removed as requested by the fire officer, which minimises the risk of fire due to combustible materials. All fire exits were clear and free from obstruction which minimises the risk of harm to service users in the event of an evacuation of the home. At the previous inspection it was identified that some doors are propped open at the request of service users. The doors need to be fitted with magnetic door closures to ensure the service users are safe in the event of a fire-taking place. A member of the management team explained that this work has been costed and the suggested date for this work to be implemented is October. This requirement has been restated. The environmental health officer visited on 23/01/06 and standards were found to be good. The water certificate was seen and found to be in order. The company insurance was seen and found to be in order. The electrical certificate was found to be in order and portable appliance testing certificate was seen dated 21/07/06. The lift was serviced on 26/01/06. All of the above actions ensure that the quality of care offered to service users living in the home is improved and service users’ health and safety is promoted. Reardon Court DS0000033461.V301098.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 3 3 X X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X 2 Reardon Court DS0000033461.V301098.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 13 Requirement The registered person must ensure that the risk assessments in flat 30 are reviewed and updated. The registered person must ensure that medication is clearly recorded on the Medication Administration Records (MAR sheets) in flats 29 and 30. The registered person must prepare an action plan with time scales showing the refurbishment of the bathroom facilities in flats 11 and 30. (Time scale from the previous inspection of 31/07/06 had not been reached.) The registered person must ensure that the laundry rooms of flats 11 and 12 are modernised and redecorated. (The timescale from the previous inspection has not been reached.) The registered person must ensure that magnetic door closures are fitted if fire doors need to be left open. (Previous DS0000033461.V301098.R01.S.doc Timescale for action 10/08/06 2. OP9 13 31/12/06 3 OP21 23 (2) (a) 12/12/06 4. OP21 23 (2) (d) 11/01/07 5. OP38 23 (4) 11/10/06 Reardon Court Version 5.2 Page 25 time scale not met 31/05/06.) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Reardon Court DS0000033461.V301098.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Reardon Court DS0000033461.V301098.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!