Care Home: Limefield Court Retirement Home

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What the care home does well What has improved since the last inspection? The care plans are continually being improved so that the staff have a clearer picture of what the resident can and cannot do for themselves. The medication system is much safer. There has been a big improvement in the way that the medicines are ordered, stored and given out. New lounge furniture has been provided for the comfort of the residents. A new management structure has been introduced so that senior staff members are aware of their individual responsibility. A lot more training has been provided for the staff. This is to make sure that the residents are cared for properly and safely. Management continue to improve the way that they check out the quality of care and the services provided for the residents. They have exceeded the standard expected. The home has achieved the Investors in People Award. . What the care home could do better: To protect the residents from harm, management must ensure that the residents who occupy the bedrooms with unguarded radiators have a personal risk assessment in place. CARE HOMES FOR OLDER PEOPLE Limefield Court Retirement Home 15 Limefield Road Bury Lancs BL9 5ET Lead Inspector Grace Tarney Unannounced Inspection 8th April 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Limefield Court Retirement Home DS0000068200.V362102.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Limefield Court Retirement Home DS0000068200.V362102.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Limefield Court Retirement Home Address 15 Limefield Road Bury Lancs BL9 5ET Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0161 761 5164 0161 7629316 youssefrd@aol.com Lily Care Limited Pamela May Hall Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (31), Physical disability (1) of places Limefield Court Retirement Home DS0000068200.V362102.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 32 service users to include: *up to 31 service users in the category of OP (old age not falling within any other category). *up to 1 named service user in the category of PD (physical disability under the age of 65 years). 5th June 2007 Date of last inspection Brief Description of the Service: Limefield Court is a two-storey property that has been extended and converted and it is situated off a main road on the outskirts of Bury Town Centre. It is within easy reach of bus routes and is not too far from the motorway network. The home has 20 single bedrooms and 6 double bedrooms. All the bedrooms except for 2 singles have an en-suite toilet and hand-basin. The bedrooms on the first floor are reached either by stairs or a passenger lift. There is also a stair lift within the home. There is a large lounge and separate dining room on the ground floor and bathrooms and toilets on both floors. There is plenty of parking and large safe garden areas with seating for the residents The home is registered to care for up to 32 people who need residential personal care. The fees for the home are set at £377.80 for residents funded by the Local authority to £380.00 for residents who pay for their own care. Additional charges are made for private chiropody, hairdressing and newspapers. This information was received on the 8/4/2008. A copy of the most recent inspection report is displayed in the entrance hall. Limefield Court Retirement Home DS0000068200.V362102.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The home was not told that this inspection was to take place although many weeks before the inspection, questionnaires (comment cards) were sent out to the residents, their relatives and the staff. The questionnaires asked what people thought about the care and quality of the service provided. 2 were received from residents and 2 from relatives. What they felt about the care and services provided is written in different sections throughout this report. Also before the inspection we (The Commission) asked the manager of the home to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they did at present, what they felt they did well and what they needed to do better. This helps us to determine if the management of the home see the service they provide the same way that we do. We spent 8 hours at the home and during this time we examined care records and medicine records to make sure that the health and care needs of the residents were being met. We also looked around the building at some of the bedrooms, bathrooms, toilets and sitting areas to check if they were clean, warm and well decorated. We also looked at the menus and looked at what the residents had for their breakfast, lunch and evening meal. We also checked how many staff were provided on each shift to make sure the residents needs were being met, and also looked at how management recruit and train their staff. We also looked at how management check that the care and services that they provide is what the residents and their relatives want, or expect. How the home manages the residents’ spending money was also looked at. In order to get further information about the home we also spent time speaking to 2 residents, 1 visitor, 3 care staff and the cook. Limefield Court Retirement Home DS0000068200.V362102.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The care plans are continually being improved so that the staff have a clearer picture of what the resident can and cannot do for themselves. The medication system is much safer. There has been a big improvement in the way that the medicines are ordered, stored and given out. New lounge furniture has been provided for the comfort of the residents. A new management structure has been introduced so that senior staff members are aware of their individual responsibility. A lot more training has been provided for the staff. This is to make sure that the residents are cared for properly and safely. Management continue to improve the way that they check out the quality of care and the services provided for the residents. They have exceeded the standard expected. The home has achieved the Investors in People Award. Limefield Court Retirement Home DS0000068200.V362102.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. The summary of this inspection report can be made available in other formats on request. Limefield Court Retirement Home DS0000068200.V362102.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 Limefield Court Retirement Home DS0000068200.V362102.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are properly assessed before they are admitted to the home and this gives an assurance to everybody that a person is only admitted if the staff can meet their needs. EVIDENCE: Before any resident was admitted to the home a senior member of staff from the home undertook an assessment of their needs. The assessment looks at what help and support the prospective resident needs in all aspects of daily life. The 2 assessments looked at were detailed and gave a clear indication of the residents’ needs and what they could and could not do for themselves. Standard 6 does not apply. The home does not provide Intermediate Care. Limefield Court Retirement Home DS0000068200.V362102.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 good. This judgement has been made using available evidence including a visit to this service. The care plans show what care needs the residents have and care practices ensure that their needs are met in a safe, caring and dignified way. EVIDENCE: Individual care plans were in place for each resident. The care plans of 2 of the residents were looked at. They were very detailed and gave clear instruction and guidance on how the care needs of the residents were to be met. They also provided a lot of information about the residents’ daily routine, their past life and their interests. The care plans were reviewed regularly so that any change in their condition could be identified and appropriate action taken. We saw evidence of the management inviting family/representatives to a meeting to discuss any issues about the care of the resident and to be further involved in drawing up the care plan with the resident and the staff. Limefield Court Retirement Home DS0000068200.V362102.R01.S.doc Version 5.2 Page 11 The care plans detailed the religious and cultural needs of the residents. At the time of the inspection there were no residents of any ethnic minority. Neither were there any residents who required special diets to meet their religious or cultural needs. The staff on each shift write a report about how the residents have been during that time. They were not, however, writing the times that the report had been written. They were writing in the initial of the shift, for example N for nights. To give an accurate record it is strongly advised that staff time their entries in the reports. Instead of writing their name on the report staff were also only initialling them. It is recommended that they write their full name or have a signature list so that it is very clear who is writing the report. The staff looked at whether or not there was any risk in relation to the residents developing pressure sores, any risk of falling and also if they were at risk due to problems with their diet and fluid intake. They also looked at and they wrote down how any resident was to be assisted with being moved around and by how many members of staff and what equipment, if any, was to be used to assist in safe moving and handling. They also assessed if there was any general safety risk, for example the use of a kettle in a residents’ room. If a risk was identified then a clear plan of action to reduce or manage the risk was put in place. The following were some of the comments made by relatives and residents • I am happy here. The staff are nice. The care is good for me. • They are looking after my mum very well. • They are vigilant when controlling medication. Inspection of the care files showed that the residents had access to health care professionals, such as dentists, opticians, district nurses and chiropodists. A safe system of medicine management was in place. The home does not have a separate medicine room. Medicines are kept in the dining area of the home in locked cupboards and in the medicine trolley. The medication keys were held securely and the trolley was secured to the wall when not in use. Controlled drugs were stored and recorded, correctly and safely. The following needed putting right: • A handwritten prescription for a painkiller stated that the resident was to take one or two every four to six hours when required. Staff were not always writing whether one or two had been given. It is important to do this to ensure that staff are aware of just how much pain killer the resident has had. Also the staff did not write on this prescription that no more than eight tablets were to be given in a 24-hour period. This is to make sure that the resident is not given too much medication. Limefield Court Retirement Home DS0000068200.V362102.R01.S.doc Version 5.2 Page 12 • A medicine that was not a controlled drug was being stored in the Controlled Drug Cupboard. The law requires that only controlled drugs should be stored in this cupboard. The owner removed the medicines whilst we were present. Staff were discreet when providing assistance to the residents. Staff were seen knocking on bedroom doors before entering and speaking to residents in a quiet and respectful way. Staff confirmed that the importance of ensuring privacy, respect and dignity is part of their initial training. The residents looked clean and comfortable and were suitably dressed. One comment made was: • Very courteous and polite staff. . Limefield Court Retirement Home DS0000068200.V362102.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. Residents are able to exercise choice and control over their lives and are given a choice of well-balanced and nutritional meals. EVIDENCE: The residents’ routines of daily living and their social interests were recorded in their care plans. The majority of residents had a Church of England or Roman Catholic religious faith and staff told us that the clergy visit the home on a regular basis. The home does not employ its own activities person, however activities from outside are arranged every week. The deputy manager has the responsibility for ensuring that activities take place. The residents have one-to-one sessions, card games, manicures, bingo and sing a longs. On the inspection site visit we saw that the residents were having baking sessions and were making buns. The residents and staff seemed to be enjoying themselves. Management has recently started publishing a magazine for the home. It is called Everybody and includes the homes news, entertainment articles and contributions from residents and relatives. Limefield Court Retirement Home DS0000068200.V362102.R01.S.doc Version 5.2 Page 14 Comments from residents were: • There is always something that I like. • We play bingo, sing with active minds and play quizzes. A visiting relative told us that she is always made welcome and can visit at any reasonable time. She told us that the staff always keep her informed about her relatives’ condition. She commented: I have nothing but praise. Staff told us that the residents are encouraged to bring personal possessions into the home. They now have a lockable space in their bedroom to keep anything that is of importance or value to them. We saw that many of their bedrooms were personalised with pictures, photographs and ornaments. We did not eat with the residents but saw what they were having for lunch. The meal served was home cooked, plenty of it, and it looked appetising and nutritious. The residents have a choice of food at breakfast, lunch and teatime. The residents have the main meal at lunchtime and the lighter meal in the evening. Inspection of the menus and a discussion with the cook showed that a 3-course meal is always offered Any cultural or dietary needs, likes and dislikes were looked at when a resident is first admitted to the home. The dining room was a pleasant area and the tables were nicely set. Hot and cold drinks were served during the meal and throughout the day Comments from residents were: • The food is excellent. • Good food always. • The cook is good. There is always a variety of food. • The food is delicious. They prepare what you ask for. Limefield Court Retirement Home DS0000068200.V362102.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. People feel able and know how to complain, and staff have a good knowledge and understanding of what abuse is, thereby reducing the possible risk of harm to residents. EVIDENCE: A detailed complaints procedure was in place and was displayed in the reception area and in each residents’ bedroom. The complaints procedure was also included in the Service User Guide. It is easy to understand and gives an assurance that complaints will be responded to within 28 days. A record is kept of any complaint made and includes details of the investigation and any action taken. No complaints have been made to the CSCI since the last inspection. A resident made the following comment: • I know how to complain if I had to. I would speak to either the senior or the manager. If not then would speak to the owner A discussion with staff showed that they were very aware of the procedure to follow in the event of any allegation of abuse of a resident. Limefield Court Retirement Home DS0000068200.V362102.R01.S.doc Version 5.2 Page 16 Training in the protection of vulnerable adults has been undertaken by nearly all of the staff and is planned for others. Records of their training were kept on file. Limefield Court Retirement Home DS0000068200.V362102.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 24 25 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live in clean, suitably adapted and comfortable surroundings. EVIDENCE: The front door is kept locked for security reasons and an intercom system is in place. The corridors are wide with grab rails along the side to assist the residents with mobility problems. The radiators along the corridors were guarded to protect the residents from any accidental harm from burning. There is a large lounge and separate dining room on the ground floor. Both of these were clean, warm and well decorated. New lounge chairs had been purchased and a resident told us that her chair was very comfortable. There were enough toilets and bathrooms to meet the needs of the residents. Apart from 2,each bedroom had its own en-suite toilet and hand basin. Limefield Court Retirement Home DS0000068200.V362102.R01.S.doc Version 5.2 Page 18 Each toilet and bathroom had a lock on the door to ensure privacy and the facilities were clearly marked as such. Not all of the bedrooms were looked at during this site visit. Those that were looked at were clean, warm and suitably furnished. They had a lockable space for the residents to store anything that was important or valuable to them. Most of the bedrooms continued to have an unguarded radiator both in the bedroom and the adjoining en-suite toilet. The home was adequately heated. All the rooms were centrally heated with radiators in place, however apart from the corridor radiators, they were not suitably protected to prevent any accidental burning. Whilst the owner has undertaken risk assessments with regards to the temperature of the radiators it was emphasised that the residents who occupy the bedrooms must have a risk assessment undertaken. If a resident is at risk of falling, then action must be taken to ensure that the radiator in their room is suitably protected to prevent accidental burning. The owner told us that eventually all the radiators throughout the home would be covered but this would be an ongoing process and they would be fitted according to the risk each radiator presented. The home was clean and free from odours. Hand washing facilities were in place in bedrooms, bathrooms and toilets. In addition, antibacterial hand cleaning gel for general use was mounted on walls throughout the home. Disposable gloves and coloured aprons were provided for staff use. A relative commented: • It is always free from smells. The two cleaners work hard. The laundry area was clean, well equipped and looked well organised. Limefield Court Retirement Home DS0000068200.V362102.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. The residents’ needs are met by staff that are suitably trained and safely recruited. EVIDENCE: A discussion with the manager, inspection of the duty rotas and comments from staff and residents showed that there was enough staff on duty to meet the needs of the residents. The information from the AQAA document sent to us, and the information that we looked at in the training file, showed that 62 of the staff had obtained their NVQ level 2 in care. This is very good progress. We were also told that the cook has recently obtained her NVQ level 2. The personnel files of 3 staff members were inspected. All were in order and these staff had been properly and safely employed. This helps protect residents from being cared for by unsuitable people. The information received from the AQAA document showed that management provide a staff induction programme for all newly employed staff. This is to make sure that they understand what is expected of them and that people are cared for properly and safely. Limefield Court Retirement Home DS0000068200.V362102.R01.S.doc Version 5.2 Page 20 A wide range of appropriate and ongoing training in moving and handling, detection of abuse, dementia care, basic food hygiene, fire safety, health and safety, medicine management and other relevant topics are provided to staff at the home. We saw that the training provided to individual staff is recorded in detail in the training file. The training is run in conjunction with Bury Adult Training Partnership. Limefield Court Retirement Home DS0000068200.V362102.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 & 38. 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 good management team in place. They continually look at the care and facilities they provide so that the residents’ welfare is protected. EVIDENCE: A new manager has recently been appointed. She has the Registered Managers Award and has worked in the care home industry for over 16 years, 7 of them as a manager. She has yet to register with the Commission. Although the manager has the overall responsibility to manage the home the owner has allocated different management responsibilities to 2 of his other senior staff. All the staff involved told us that they are happy with this arrangement. Limefield Court Retirement Home DS0000068200.V362102.R01.S.doc Version 5.2 Page 22 A great deal of work has gone into developing a quality assurance system for the home. This is to check on the quality of the care and services provided. Management has now introduced a Suggestion Box that is situated in the entrance hall. A management meeting is undertaken on a weekly basis and all staff members in management are expected to attend. Staff meetings are held monthly and resident and relative meetings are held every six months. We saw evidence of these meetings. Staff confirmed that the owner continues to visit the home most evenings to make spot checks, discuss any problems, check on supplies and talk to staff, residents and visitors. We saw copies of the different questionnaires that are sent out to residents and relatives asking for their views about the care and facilities provided by the home. Questionnaires are also sent out to staff. The owner has looked at the information returned from all the surveys, has collated the information and then displayed the results within the home. That is extremely good practice. The AQAA form that was sent to us informed us that the home has achieved the Investors in people Award. The system for the safekeeping of residents’ money was good. Management only handle any “spending money” brought in by relatives. Individual records are made of all transactions and balances. Receipts are held for any purchases made and receipts are given to relatives when they deposit any money for their relative. Information received from the AQAA sent to us and from random checking of servicing records showed that the homes’ fixtures, fitting and equipment are properly maintained and regularly serviced. We saw that regular weekly checking and testing of fire detection system, fire exits and emergency lights was undertaken and documented. The concerns identified during the last two inspections in relation to the unprotected radiators remain. The owner has made progress by fitting radiator covers to those radiators considered by him to be a greater risk. He told us that the fitting of radiators would be an ongoing process. Limefield Court Retirement Home DS0000068200.V362102.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 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 x 3 x x 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 4 x 3 x x 3 Limefield Court Retirement Home DS0000068200.V362102.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement To ensure that the residents receive the correct amount of medication, staff must ensure that they write down precisely what dose of medication has been given. To protect the health and safety of the residents, the system of undertaking individual risk assessments on the residents in relation to the unguarded radiators, must continue and appropriate action taken to reduce any risk identified. Timescale for action 08/04/08 2. OP25 13(4)(a) 08/04/08 3 OP31 CSA 2000 The manager must apply to be Section 11 registered with the Commission. 31/05/08 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 Limefield Court Retirement Home DS0000068200.V362102.R01.S.doc Version 5.2 Page 25 Limefield Court Retirement Home DS0000068200.V362102.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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