Inspection on 20/04/07 for Redclyffe

This inspection was carried out on 20th April 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

Redclyffe 14/06/06

Redclyffe 13/12/05

Redclyffe 23/06/05

Redclyffe 28/01/05

Redclyffe 26/04/04

Redclyffe 22/12/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Redclyffe 6/8 Aldrington Road London SW16 1TP Lead Inspector Davina McLaverty Unannounced Inspection 10:00 20th April & 4th May 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 Redclyffe DS0000010220.V336318.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. Redclyffe DS0000010220.V336318.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Redclyffe Address 6/8 Aldrington Road London SW16 1TP 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) 020-8769 6200 020 8769 6200 yvonne.wallace2@btinternet.com Richard Cusden Homes Ms Yvonne Wallace Care Home 22 Category(ies) of Dementia (6), Old age, not falling within any registration, with number other category (22) of places Redclyffe DS0000010220.V336318.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27TH November 2006 Brief Description of the Service: Redclyffe, is a residential care home for older people that is owned and operated by the voluntary organisation, Richard Cusden Homes (non profit provider) and is located in a leafy, residential area of Streatham. The property comprises of two attached, but formerly detached, large Victorian houses in their own grounds. A small car park is available. Public transport and local shops are nearby. The home is registered for twenty-two service users, six of whom may suffer with dementia. Sixteen of the bedrooms have en-suite facilities. The atmosphere is homely and relatives are encouraged to visit and take part in the life of the home. At the time of this inspection the manager of the home reported that the weekly fees were £540 per week. Additional charges are made for toiletries, newspapers and some outings. Residents are made aware of the inspection report through individual discussion as well as a copy being displayed in the hallway. Redclyffe DS0000010220.V336318.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one and a half days by one regulatory inspector. The pharmacy inspector inspected the home’s medication on the first day of the inspection and her findings and requirements have been inserted into the report. The inspector met the majority of residents, the manager and her deputy; four support staff and two visiting relatives. A number of records were sampled, which included residents care plans, staff records, staff meeting minutes, supervision records, and health and safety records. A tour of the premises took place. Ten resident questionnaires, ten staff questionnaires and ten visitors /friends/advocates questionnaires were left at the home at the end of the first day for the manager to distribute. Six professional questionnaires were sent out by the inspector whose names were taken from care plans sampled. A total of six questionnaires were returned at the time of writing this report. What the service does well: What has improved since the last inspection? The number of reviews of residents care needs, has increased as a result of one the Local Authority allocating a care manager who is responsible for carrying out all residents reviews as well providing advice and support to the home. A bathroom on the second floor has been completely refurbished with a hoist. Redclyffe DS0000010220.V336318.R01.S.doc Version 5.2 Page 6 Morale within the home: in view of the home negotiating with the local council, a more appropriate weekly fee, which will enable the home to employ two more support staff and another waking night staff. The home has also secured an additional grant, which will enable new carpets, decoration and replacement of some furniture to take place later in the year. Increased training of all staff in particular dementia care, which is impacting on the overall care of residents. 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. Redclyffe DS0000010220.V336318.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 Redclyffe DS0000010220.V336318.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, 4 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs and wishes of prospective residents are assessed prior to them moving into the home. This makes sure that staff are aware of and can meet these needs. EVIDENCE: The majority of the residents are placed by Wandswoth Social Services unless they are self funding. Staff from social services carry out an assessment of the needs of the person. A copy of which is sent to the home for consideration of the person’s suitability. The manager or a senior staff member will then carry out their own assessment to ensure that the person’s needs can be met. A brief assessment report is written by senior staff on all residents prior to admission. Where residents are self funding, the home was able to demonstrate how they undertook the assessment. Where possible potential residents or their representatives, are encouraged to visit the home prior to admission. The first six weeks are seen as a trial period, after which a review Redclyffe DS0000010220.V336318.R01.S.doc Version 5.2 Page 9 takes place to ensure that the resident is happy to stay and that staff are able to meet their needs and expectations. Intermediate care is not provided at this home. Redclyffe DS0000010220.V336318.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans in the home continue to be developed. Care plans would be further improved by increasing the involvement of residents and their relatives so that the plans reflect as accurately as possible the needs and wishes of the residents. Residents are receiving their medicines regularly however records of administration were not accurate. Residents reported that staff respect their privacy by knocking on doors and asking them what they would like. EVIDENCE: Four care plans were examined and improvement was noted in the content of the plans. Care plans evolve from the resident’s core assessment, which is carried out by social services, as well as the home’s own assessment of the person. Care plan documentation is comprehensive. Four care plans were Redclyffe DS0000010220.V336318.R01.S.doc Version 5.2 Page 11 examined and improvement was noted, although on two of the care plans seen, not all sections had been completed e.g. cultural needs, resident daily routine. No evidence of resident being involved or consulted about their care plan was seen, although staff said that they go through the care plan with their key clients. Two plans did not contain a current photo of the resident. Monthly reviews were not always in place. Resident’s files contained an assessment of risk and how these risks were to be dealt with and reduced as far as possible. Details of hospital, GP, chiropodists and district nurse appointments were seen on the files examined. Feedback from residents regarding visits to health care professionals was positive. Relatives spoken with stated the home’s commitment to keeping residents as well as possible. One resident said that the district nurses who visit are good; another spoke of positively of the weekly hairdresser. All residents spoken with appeared well cared for. All were appropriately dressed and well groomed. Staff spoken with said that they encouraged residents to do as much for themselves as they are able e.g. choose their clothes, carry out their own personal care. One resident spoken with said that staff respected her privacy and always knocked and waited to be invited in. Several said that the staff were helpful and kind. Medication Administration Record (MAR) charts for all residents were inspected, and there were a significant number of missing signatures on almost all charts. On checking stocks, medication had been given, however staff had forgotten to sign for administering. Some missing signatures were for medicines administered several weeks earlier Records of receipt of medicines were accurate. Records of returns were not available as the logbook was with the supplying Pharmacist. This will be checked at the next inspection. All permanent staff who administer medicines have had appropriate training, and are due refresher training in May 2007. Medication induction training for all carers is important as carers must be aware of what medicines are used for and potential side-effects in order to effectively monitor residents health and to be able to inform the GP if medicines are effective. The Skills For Care Medication Knowledge Set and competency assessment were recommended. The home must request evidence of medication training to ensure the competency of all agency staff before allowing them to administer medicines Patient Information Leaflets are kept, and it is recommended that medication profiles are written, using these leaflets, including for example what each Redclyffe DS0000010220.V336318.R01.S.doc Version 5.2 Page 12 medicine is used for, potential side effects, and start and stop/change dates to increase staff knowledge on what the medicines they are administering are for Storage facilities were appropriate, the fridge temperature is now being recorded, and locked storage is available in residents rooms to store medicines securely. A risk assessment is now in place for a resident who self-administers their medicines. Redclyffe DS0000010220.V336318.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Redclyffe is good at making residents feel comfortable and at home. Residents have access to some activities arranged at the home, which continues to be developed. Residents are encouraged and supported to maintain contact with family and friends. A varied diet is offered, which residents input to. EVIDENCE: An activity programme is in place, however, activities vary depending on staff time. The manager reported that with the proposed increased in staff, activities within the home would be developed further. Staff endorsed this and drew reference to recent training on dementia care, which enabled staff to see how much more could be done with the residents. The home continues to use the services from adult education, however this has been reduced to one hour and consists of reminiscence, as well as music and movement. Staff support Redclyffe DS0000010220.V336318.R01.S.doc Version 5.2 Page 14 the facilitator to enable as many residents to participate. Three residents spoke of their enjoyment at these sessions. The manager said she is currently looking at whether the home can afford to employ her services another day. Piano playing and singing also takes place once a week. Again residents spoke positively about this. A record is kept of activities that take place. The mobile library continues to visit and loans the home a number of large print books. All staff endeavours to carry out individual activities with a small group of residents e.g. playing board/card games, art and crafts as well as group discussion. Staff reported that following one of the dementia training sessions, the tutor helped them set up a small tea party for some residents in the home which was very successful, resulting in some residents being engaged in deep conversation with staff. Staff reported that further sessions are planned. A small group of residents currently attend a coffee morning at the local church. The home receives visits from several church ministers and communion is offered. A yearly trip to the coast usually takes place, although the manager reported that she may look at shorter visits to more local places e.g. Richmond park, Kew Gardens as often residents who have said they would like to go to the coast, change their mind on the day, as they no longer wished to go on a full days outing. Relatives were observed to be visiting during both days of the inspection. One couple spoken to was very positive about the home and had no issues of concerns. They stated that the home had high standards. The lunchtime meal served was observed to be well presented. However, the inspector noted that one resident, whose care plan clearly stated that he did not like peas, was given peas. Also staff were observed to serve the dessert to some residents before they had finished their first course. Staff however, were observed to assist as required. Three residents who ate slowly were left to complete their meals when the other residents were taken back to the lounge. The inspector noted that condiments were on the table for residents to help themselves to. Lunch was seen to be an enjoyable and relaxing time with some conversation between residents taking place. Redclyffe DS0000010220.V336318.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure in place. Residents and visitors confirmed that they were aware of the procedure. All staff receive training on the protection of vulnerable adults, which ensures they are aware of their responsibilities in relation to protecting residents. EVIDENCE: The current complaints procedure is provided to residents in the service user guide. The complaint policy displayed in the home is the previous one and must be updated. There are clear timescales for responding to any complaint made and information on the process if the complainant remains unhappy. Systems are in place for recording any complaint along with information on outcomes. The manager confirmed that no complaints have been received since the previous inspection. The CSCI have not received any complaints about this service. Visitors expressed confidence in the staff and manager to deal with any problems or concerns they may have. Some individuals spoken with did not know how to make a complaint, although one resident stated, “you can talk to staff about anything that is troubling you and they will do their best to sort it out”. The organisation has in place procedures for staff should they receive any allegations of abuse, or have any concerns regarding the safety of residents. Redclyffe DS0000010220.V336318.R01.S.doc Version 5.2 Page 16 The home also has a copy of the local authority procedures for reporting of and investigation of abuse. All staff have had training around safeguarding adults. Redclyffe DS0000010220.V336318.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are provided with a comfortable and clean environment, however, refurbishment of the premises is needed in certain areas to enhance the environment. EVIDENCE: The home is reasonably well maintained and provides a comfortable environment for residents. Plans are in place for essential maintenance work to be carried out later in the year. This includes replacement of hallway and stair carpets as well as redecoration of several resident’s bedrooms and the corridors on the first and second floor of the home. The manager and her staff team are looking at how the redecorating could incorporate the needs of residents suffering with dementia e.g. different colours for each floor, more signage. Redclyffe DS0000010220.V336318.R01.S.doc Version 5.2 Page 18 The home was described by residents as “very pleasant” and “comfortable”. Relatives spoke of the high attention that is paid to hygiene within the home and said that they have always found this to be the case and that they had been visiting a number of years. Since the last inspection the home has had installed a new bath and hoist on the second floor. Plans are also in place to renovate the current assisted bathroom to make it more accessible and attractive to residents. Liquid soap and paper towels were observed in all the bathrooms and toilets. A room is designated for hairdressing. The home has access to occupational therapists to ensure that appropriate aids and adaptations are available in the home. A number of raised toilet seats and grab rails were seen throughout the home. As stated carpets on the first and second floor are due to be replaced later on this year. Several bedrooms seen require decorating . The staff room also needed urgent attention, as it is very bleak in appearance. A small laundry room is available and key workers are responsible for laundering their key clients clothes. Staff reported that this worked well and no resident raised any concerns about their clothes. Residents have access to a large garden and a smaller patio area. Outdoor furniture is available and residents are encouraged to sit out in the warmer weather. Staff within the home endeavour to make the garden area attractive with various flowers. Flowering pots and baskets were seen on the patio. A number of residents spoke of enjoying the garden during the summer. Redclyffe DS0000010220.V336318.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Relationships between staff, residents and visitors are good. Care is taken to ensure that the appropriate checks are carried out on staff before they commence work, which assists in ensuring the safety of the residents. Staff are provided with opportunities for training. EVIDENCE: Since the last inspection, plans are in place to increase the number of staff per day shift by one from four to five, and at night, to have three waking night staff. This will enable staff to spend more individual time with residents, which will improve the quality of life for the residents. The home employs a cook, cleaner and handy person. Staff spoken with reported that with the additional staffing and training currently being given on dementia care, the increased staffing will ensure that sufficient staff are available to meet the needs of the residents group whose dependency levels are increasing. Staff also spoke of teamwork being a priority and one of the home’s strength in that the staff worked well together and that they was an open management style, which encouraged initiative. Staff were observed to communicate well with residents when assisting or offering support. Staff took time to explain what they were doing and responded when asked a question or when residents Redclyffe DS0000010220.V336318.R01.S.doc Version 5.2 Page 20 were making general comments. Staff were seen to have created a relaxed and open atmosphere where residents felt comfortable in asking questions. Staff are offered opportunities for training, and recent training has included manual handling, first aid, infection control, food hygiene and the safeguarding of vulnerable adults. Dementia care training is currently taking place and staff spoken with commented positively regarding the course and trainer, who is hands on and has been into the home to advise and show staff activities they can do with residents, which staff reported significantly enhanced the residents communication skills. The manager is still in the process of updating staff training records. Significant improvement was seen in this area. Staff have opportunities to complete NVQ training and the majority of the staff team have completed this training. An induction programme is in place in the home. Four staff files were examined, and appropriate checks are carried out including two written references and criminal records bureau checks. This assists in protecting the safety of residents. However, the manager must ensure that there is a current photograph of each staff member on their files, as this was not seen on two of the files examined. Residents and visitors provided very positive comments on the staff and their approach. Staff were described as “very good”, “very kind and patient” and one resident said, “they always try and help you if you have a problem”. Similar comments were received from relatives and friends, who also said that staff always made them feel welcome at any time. One relative questionnaire said, “This is an extremely happy and well run home -the family cannot speak too highly of the staff”. Redclyffe DS0000010220.V336318.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents continue to benefit from a well run home with the manager providing clear direction and leadership within the home. A quality assurance system is in place, which takes into account the views of relatives and other stakeholders. Staff carry out health and safety checks in the home, however, a system of monitoring these checks must be put in place to fully ensure the health and safety of staff and residents. EVIDENCE: The registered manager has the appropriate qualifications and experience for her role. Positive comments were received from residents and visitors to the home regarding the manager. She was described as very knowledgeable on the needs of each individual and is approachable. Staff reported that they feel valued and are very much part of a team in which their comments are listened Redclyffe DS0000010220.V336318.R01.S.doc Version 5.2 Page 22 to. Relatives also reported that the manager is approachable and takes on board their views whilst respecting the rights of the resident. The home manager continues to take part in regular training to ensure that she maintains up to date knowledge. A quality assurance system is in place in which the views of residents, relatives and other stakeholders are sought. Questionnaires had recently been sent out and the Chair of the Committee would be responsible for analysing the comments and writing a development plan. A sample of three residents money were examined, of which two were correct and tallied with the written records seen. The third one failed to, although following the inspection, the manager submitted details as to why there was a shortfall in this case. Supervision was seen to be taking place with clear records being maintained. Health and safety systems are in place. Records examined included COSHH assessments, which had been updated as required at the last inspection. Portable appliance tests were seen to be in order. Fridge and freezer temperatures need overseeing as various gaps were noted, which potentially could place residents at harm. The recent fire-training certificate displayed in the hall referred to the previous legislation and requires amending. All fire drills must be recorded following completion of the drill. A copy of the landlord’s gas certificate was seen. The lift is serviced six monthly and a qualified first aider is available on each shift. Redclyffe DS0000010220.V336318.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X 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 2 3 X 2 3 X 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 3 X 3 X 3 3 X 2 Redclyffe DS0000010220.V336318.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 15(2) (b) (c) Requirement Care plans must clearly identify resident’s needs and be reviewed monthly. Decisions following annual reviews must also be integrated into a new plan. (Previous timescale of 30/07/06 not fully met.) All carers must receive medication induction training. and their competency assessed before allowing administration of medication. Staff must ensure that all records of medication administration are accurate and that medicines are signed for at the time of administration. An updated maintenance/refurbishment plan for the home must be submitted to the Commission with dates as to when the work will be carried out. All staff must have a training plan, which clearly evidences core training undertaken, and DS0000010220.V336318.R01.S.doc Timescale for action 30/06/07 2 OP9 13(2) 30/07/07 3 OP9 13(2) 30/06/07 4 OP19 18(1) 30/07/07 5. OP30 18(1) (c) 30/07/07 Redclyffe Version 5.2 Page 25 when refresher courses should take place. (Timescale of the 30/09/06 not fully met) 6 OP38 13(4) (c) Fridge and freezer temperatures must be taken daily and action taken where temperatures are too high or low. All fire drills must be recorded. 30/04/07 7 OP38 23(4) (e) 30/04/07 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 OP9 Good Practice Recommendations Medication profiles are written for each resident so that staff know what each medicine is used for and are able to effectively monitor healthcare conditions. A current copy of the complaints procedure should be displayed on the notice board. The notice board should only contain current information. Staffing levels must continue to be kept under review to ensure that residents needs can be met during the day and at night. 2. OP16 3 OP27 Redclyffe DS0000010220.V336318.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Redclyffe DS0000010220.V336318.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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