Inspection on 26/09/05 for Reardon Court

This inspection was carried out on 26th September 2005.

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

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

Other inspections for this house

Reardon Court 10/07/06

Reardon Court 07/03/06

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 Unannounced Inspection 26th September 2005 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.V249444.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V249444.R01.S.doc Version 5.0 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 4807 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.V249444.R01.S.doc Version 5.0 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.V249444.R01.S.doc Version 5.0 Page 5 Date of last inspection 12th January 2005 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 day centre, sheltered accommodation and an outreach service. Reardon Court is a quiet, secluded residential area close to open land, transport links and the shops and services of Winchmore Hill. Reardon Court DS0000033461.V249444.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection of Reardon Court took place over one day. The inspector was able to speak to nine service users, twelve care staff and members of the management team in groups and on an individual basis. The inspection involved a tour of the premises and a range of documentation was examined, such as health and safety documents. Separate discussions subject to negotiation with the local authority are ongoing due to outstanding requirements. Nineteen service user comment cards were returned, seven comment cards from professionals and nineteen from relatives. The inspector would like to thank the staff and service users for their cooperation during the inspection process. Marilyn Mackenzie, Pharmacist, carried out an inspection visit on the 5th October 2005 for the Commission for Social Care Inspection. Her findings are included in this report. What the service does well: What has improved since the last inspection? The kitchen in flat 11 has been replaced. The frequency of fire drills has increased. Service users are now receiving their dental checks. The staff in flat 29 have training in relation to strokes, fractures and broken bones. Reardon Court DS0000033461.V249444.R01.S.doc Version 5.0 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.V249444.R01.S.doc Version 5.0 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.V249444.R01.S.doc Version 5.0 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, 3, 5 Service users are given the information they need, to make an informed choice about whether the home is suitable for them and their needs. They are assessed prior to them moving to the home. The admission procedure is well designed and there are opportunities for service users and their families to visit prior to admission. EVIDENCE: The inspector noted that there is an up to date service user guide. This information can also be translated if required. The home makes available to service users a welcome pack. The home has a statement of purpose which is made available to service users and is up to date. The inspector examined a sample of service users files. These contained signed contracts/statement of terms and conditions and all of the pre and post admission information. There was evidence that prospective service users were able to visit the home before admission. During a discussion with a service user about this process he stated that the home was like a hotel and that he and his family have been made to feel very welcome. Reardon Court DS0000033461.V249444.R01.S.doc Version 5.0 Page 10 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 The health and personal care needs of service users are met. There was a clear consistent care planning system in place. Personal support in the home is offered in such a way as to promote service user privacy and dignity and there was evidence to show that service users wishes in relation to their death had been noted. However, service users risk assessments need to have detailed information in relation to cot sides to ensure service users are not placed at risk. The service users are protected by the home’s medicines policies and procedures. The adherence by staff to these procedures is mainly satisfactory. EVIDENCE: The service user care plans were inspected and were up to date. The format of the care plan showed each identified assessed need or aspiration, the desired outcome of these and guidance to staff on how to achieve the outcome. The care plans are being reviewed by the home on a monthly basis and were informed by a range of multi-disciplinary reviews and relevant risk assessments. The inspector noted that cot sides were being used for a number Reardon Court DS0000033461.V249444.R01.S.doc Version 5.0 Page 11 of service users (flat 11). It is necessary for risk assessments to be developed for each service user for whom cot sides are used, to include the risks associated with their use. A requirement has been made in relation to this. There were good records of visits and appointments with the GP, who visits the home regularly and evidence on service users files to indicate they had appropriate access to a range of health care services, such as dentists and chiropodists. The medicines policy is complete. The records for the ordering and receipt of medication are computerised and this also enables a medication history to be maintained. For respite and rehabilitation service users the amount of medication returned to them on discharge is also entered on to the data base. The staff identify who has entered the information on to the data base by use of their initials but this is not password protected. [requirement made]. The administration charts were being completed correctly except in one case ‘tipex’ was used to obliterate an initial which had been entered in error. The deputy manager stated that she would immediately issue a notice to stop this happening again. The recording of the administration of homely remedies was not standardised across the home; units were entering them in varying places. [Requirement made] Senior authorised staff are sometimes adding to the pharmacy dispensed boxes rather than leaving the medication in the pharmacy labelled bottles and containers. [Requirement made]. Senior staff are filling dosette boxes for some respite service users and occasionally for the rehabilitation service users. The staff are recording this process and another senior member of staff is checking that the contents of the boxes are correct. The boxes are labelled with the contents of the box. There is also a problem with some of the families of respite service users filling dosette boxes for their relatives and giving these to staff to administer. These boxes are often insufficiently labelled. [Requirement made]. The medication is stored in locked cupboards fixed to the wall in the units but the temperature of these cupboards can exceed 25oC. [Requirement made]. One of the cupboard fixtures to the wall was broken. The Controlled Drugs are stored in a separate cupboard inside an outer cupboard inside a small room. The administration of Controlled Drugs is recorded in a Controlled Drug Register. The refrigerator was not consistently being maintained between 28oC but at the time of the inspection no medication requiring storage below 12oC was being kept. The inspector spoke with five service users in private and they all confirmed that staff are sensitive in their approach. Staff were observed as being courteous to service users and knocked on bedroom doors before entering service users rooms. All service users have their own key to their bedroom made available to them. Discussion with staff and service users indicated that all personal care was given in the privacy of their bedrooms or bathrooms. The inspector found that the wishes of service users in relation to their death are recorded in their files. This area is also commented on in Reardon Court’s guide for service users. Reardon Court DS0000033461.V249444.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14, 15 Service users can be confident that they will be facilitated to maintain contact with their family and friends. Service users are encouraged to make choices in their lives. The home provides good quality food in a pleasant and relaxed environment with their preferences catered for. However, food is not stored correctly, which places service users at risk. EVIDENCE: The inspector observed relatives visiting service users in flat 29 who were undisturbed by staff. One relative stated their family members were made to feel welcome and they could not wish for better care and that there is a nice caring atmosphere in the home. The inspector noted that individual service users plans set out peoples’ hobbies and interests and information about the social side of their lives such as contact with their friends and family. The food menus were inspected and indicated that choice was available for service user in relation to what they chose to eat. The inspector observed service users eating their meal (in flat 11) which was nutritious, balanced and was provided in sufficient quantity. The food was appealing and there was Reardon Court DS0000033461.V249444.R01.S.doc Version 5.0 Page 13 evidence of fresh fruit and vegetables available throughout the home. All service users spoken with said they enjoyed the food provided. The kitchens were clean and tidy in all units. The kitchen in number 11 had been replaced, which was a requirement made in the last inspection. The kitchens in both 12 and 30 need replacing. A requirement has been made in relation to this. Food was stored within its sell by date but in the kitchens of units 11 and 30 food had not been stored appropriately. Tins had been opened and the contents had been stored within this tin in the fridge. A requirement has been made in relation to this. Fridge and freezer temperatures were being maintained appropriately in all units. Meat temperatures had also been recorded. It was noted that a service user in flat 11 has her food pureed. This food should be pureed separately to enhance appearance, allow the different textures and flavours to be experienced by the service user. A good practice recommendation has been made in relation to this. Reardon Court DS0000033461.V249444.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The written complaints procedure was adequate. The home must ensure that staff are adequately trained in relation to adult protection to ensure the home’s policy regarding adult protection can be implemented and ensure service users are protected from abuse. EVIDENCE: The complaints procedure was examined and found to be clearly laid out. The procedure in relation to when a service user is unhappy with the service they receive can be found in Reardon Court’s guide. This guide also contains information about how to contact the Commission for Social Care Inspection. The home has an adult protection procedure. However, all staff have not received training in adult protection as the deputy manager is still awaiting training dates to be provided. This is a requirement outstanding from the last two inspections and is restated at this inspection. The inspector spoke with staff in flat 30 in relation to abuse. The staff were knowledgeable about their responsibilities in relating to reporting suspicions or incidents of abuse. Reardon Court DS0000033461.V249444.R01.S.doc Version 5.0 Page 15 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, 21, 22, 23, 24, 25, 26 The service users at Reardon Court do not live in a home that is well maintained. The service users do not have access to adequate bathrooms with a range of equipment to meet their needs. The home is clean. There is a clear need for the home to be updated in relation to decoration and the equipment provided, to ensure a pleasant, safe environment is maintained for service users, staff and visitors. EVIDENCE: All service users have their own room and there are no shared rooms. The service users in the permanent flat have personalised their rooms with their own furniture and pictures. The bathrooms in flats 29 and 30 do not have adequate shower facilities due to the fact that the design of these facilities are not suitable for service users with mobility problems and therefore cannot be used as service users’ safety cannot be guaranteed. The bathrooms in flats 11 and 29 need to be updated as the Reardon Court DS0000033461.V249444.R01.S.doc Version 5.0 Page 16 manual handling equipment is very inappropriate and staff find this very difficult to use, given the undue pressure this places on their shoulder joints. A requirement has been made in relation to these areas of concern. It is required that the tiled floors in the bathrooms and showers be replaced with suitable non-slip alternatives. This requirement has been restated from the previous inspection. The weight machine being used to assess service users weight in flat 11 is broken. Service users weight has not been recorded since May 2005. This equipment needs to be replaced. A requirement has been made in relation to this. Two new electronic beds are required on both flats 11 and 29 to ensure that the home can adequately meet service users needs. A requirement has been made in relation to this. The inspector observed that the carpet in room 4 of flat 11 needs to be replaced. The carpet in the hallway also needs to be replaced. A requirement has been made in relation to this. The laundry rooms of flats 11 and 12 need decoration and modernisation. A requirement has been made in relation to this. The blinds in all bedrooms in flat 29 need replacing. The lounge needs redecorating. A requirement has been made in relation to these. Reardon Court DS0000033461.V249444.R01.S.doc Version 5.0 Page 17 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, 30 The home has a stable staff team. To assist service users and ensure their assessed needs are being met, staff need to undertake the outstanding training requirements from the previous inspection to ensure that service users are not at risk. EVIDENCE: Rotas in the various flats were inspected. Staff on duty matched those shown on the rota. The home has a stable staff group that are familiar with the service users needs. Staff have received training in first aid and food hygiene. However, not all staff have received training in adult protection which was a requirement made at the last two inspections. Staff also need to receive training in supporting people with mental health needs. This is a requirement restated from the previous inspection. The inspector saw the system in place to provide supervision to staff. Supervision needs to take place on a regular basis and whilst this has improved to some degree in flat 30, this requirement has been restated. Reardon Court DS0000033461.V249444.R01.S.doc Version 5.0 Page 18 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): 36, 38 Staff need to be supervised more frequently to ensure staff and service users needs are met. The health and safety of service users and staff are not promoted and protected. EVIDENCE: The home uses a quality assurance questionnaire to formally seek the views of service users and relatives regarding the service offered by the home and how this could be improved. The home also has a service user guide and a welcome pack available and a key worker system is in operation. The staff supervision system was inspected and a requirement has been made in relation to this. A range of health and safety documentation was seen. Regular fire drills were taking place, point testing and a fire risk assessment had been completed. The fire equipment had been serviced. The IEI building services engineers site visit Reardon Court DS0000033461.V249444.R01.S.doc Version 5.0 Page 19 sheet has stated that the fire alarm system needs to be updated. This is evidenced by written information provided by the staff at Reardon Court. A requirement has been made in relation to this. The home has an up to date liability insurance certificate. PAT testing had taken place on the 14.07.05. There was evidence that the hoist had been serviced and this was up to date. The water system had been professionally inspected to assist to minimise the danger of Legionella. Staff at Reardon Court showed the inspector a document which stated that Legionella was a very high risk in this building and staff stated that social services had taken an excessive amount of time to make this information available to the appropriate staff at Reardon Court. A good practice recommendation has been made in relation to this. The electrical certificate was seen and found to be in order. The inspector noted that some service users like their bedroom doors open, including night time. It is required that the home discusses with the fire authority what action can be taken to remedy the situation. The inspector discussed the option of door guards which can be part of the discussion with the fire officer, but until this takes place it was agreed that risk assessments will have to be completed and that checks on service users will have to be increased. A requirement has been made in relation to this. Flat 11 has a coded entry system which has recently been provided to protect the safety of those service users who wander. The home must consult with the fire authority in relation to the appropriateness of this device. A requirement has been made in relation to this. The inspector was encouraged to walk freely throughout the home and speak to staff and service users without the presence of the service manager. Reardon Court DS0000033461.V249444.R01.S.doc Version 5.0 Page 20 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 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 1 X 1 1 3 2 2 2 STAFFING Standard No Score 27 3 28 X 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 2 X 1 Reardon Court DS0000033461.V249444.R01.S.doc Version 5.0 Page 21 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 (4) Requirement The registered person must ensure that the risk assessments are developed further for each service user for whom cot sides are used, including the risk associated with their use. An action plan with time scales for the kitchens to be replaced in units 12 and 30 needs to be formulated and sent to the CSCI. The registered managers in flats 11 and 30 must ensure food is stored appropriately. Food products must be removed from tins once opened and stored in sealed containers in the fridge. It is required that all care staff receive training on adult protection issues. This is restated from the previous inspection. Time scale not met. 31.03.05. An action plan with time scales showing the refurbishment of the shower and bathroom facilities in flats 11 and 30 needs to be forwarded to the CSCI. It is required that the tiled floors in the bathrooms and showers DS0000033461.V249444.R01.S.doc Timescale for action 15/11/05 2 OP19 23 (2)(b) 18/12/05 3 OP15 16 (2)(i) 01/12/05 4 OP18 13 (6) 01/02/06 5 OP21 23 (2)(a) 18/12/05 6 OP38 13 (4)(a)(b) 01/02/06 Reardon Court Version 5.0 Page 22 (c) 7 8 OP22 OP24 23 (2)(c) 23 (2)(n) 9 10 11 12 13 OP24 OP26 OP24 OP19 OP30 23 (2)(d) 23 (2)(d) 23 (2)(c) 23 (2)(d) 18 (1)(c) 14 OP36 18 (2) 15 OP38 23 (4)(v) 16 17 OP38 OP38 23 (4)(a) 23 (4)(b) 18 OP9 13 be replaced with a suitable nonslip alternative. Restated from the previous inspection. Time scale not met. 13.12.04. The weighing machine must be replaced. Two new electric beds must be obtained for units 11 and 29 to ensure service users needs are met. The carpet of room 4 and the hall of flat 11 must be replaced. The laundry rooms of flats 11 and 12 need modernisation and redecoration. The blinds in all bedrooms in flat 29 must be replaced. The lounge in flat 29 must be redecorated. It is required that all staff receive training on understanding and appropriately supporting service users who have mental health issues. Restated from previous inspection. Time scale not met. 13.12.04. It is required that all staff have regular supervision. Restated from previous inspection. Time scale not met. 31.8.04. The registered manager and provider must consult with the fire authority in relation to service users doors being left open and what action can be taken to remedy this. The fire alarm must be updated. The registered manager and provider must consult with the fire authority in relation to the controlled access door system on unit 11. The registered manager must ensure that whoever receives the medication into the home for the month also makes a signed entry DS0000033461.V249444.R01.S.doc 01/01/06 01/02/06 01/02/06 01/03/06 01/01/06 01/01/06 01/01/06 15/11/05 01/11/05 01/01/06 01/11/05 20/11/05 Reardon Court Version 5.0 Page 23 19 OP9 13 into a medication receipts book so that the person responsibility for the receipt can be checked with the computer entry because the computer entries are not password protected. The registered manager must ensure that no medication is added to the pharmacy labelled boxes. Decanting of medication into dosette boxes by staff should be confined to those service users who are requiring dosette boxes in order to administer their own medication. The registered manager must ensure that the temperature of all areas where medication is stored is maintained below 25oC. The medication refrigerator must be maintained between 2-8oC when in use to store items requiring refrigeration. The registered manager must ensure that all medication supplied by relatives for respite service users is in fully labelled pharmacy bottles and containers which reflect the dose to be administered by staff. 20/11/05 20 OP9 13 20/11/05 21 OP9 13 20/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP15 Good Practice Recommendations It is recommended that the service user whose food is pureed is provided with meals with each food being pureed separately. DS0000033461.V249444.R01.S.doc Version 5.0 Page 24 Reardon Court 2 OP15 The registered provider must ensure that when information is sent from the head office to Reardon Court this is completed with haste and a clear communication system is put in place. Reardon Court DS0000033461.V249444.R01.S.doc Version 5.0 Page 25 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.V249444.R01.S.doc Version 5.0 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. 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!