Care Home: Reardon Court

What the care home does well A friendly flexible consistent service is provided with staff that is motivated to care for people using the service and promote its improvement. The manager and staff have a good relationship with people using the service, which ensures that people`s emotional wellbeing is maintained. The manager has updated the service user guide and statement of purpose. This ensures that up-to date information is available to people who may wish to use the service. People`s care plans in flats 11 and 12 are clear and up-to-date. This ensures people`s needs are met. People`s people`s relation being of health care records contained relevant information and indicated that health and wellbeing is promoted and protected. Procedures in to medication are good which further protects the health and well people living in the home.People are supported to exercise choice and control over their lives, which aids their self-esteem. People are provided with nutritious healthy meals, which ensures their dietary needs are met. People who use the service their friends and relatives are listened to and complaints are taken seriously. A number of environmental improvements have taken place including the refurbishment of all the kitchens, which makes Reardon Court a nicer place to live. The home is clean and well maintained, which promotes people`s health and wellbeing. Staff are adequately trained to meet peoples needs. Professional recruitment procedures are in place, which protect people living and working in the home from potential abuse. Staff supervision is taking place regularly. This ensures that people can be supported in a professional consistent way. A quality assurance system is in place, which enables the view of the people using the service to be sought so that the service can monitor the quality of the service provided. The people spoken to who use the service speak highly in relation to the service they receive. What has improved since the last inspection? The refurbishment of the bathrooms and showers in all of the flats has been completed. The communal bathrooms are currently undergoing refurbishment. This means that people`s personal care needs can be fully met in a more appropriate environment. The laundry rooms in all of the flats are undergoing refurbishment and have been equipped with more up to date machinery, which works effectively. The flats have all been furnished with new dining room tables and chairs, which ensures that people have a comfortable place to eat their meals. The blinds in all of the flats at Reardon Court have been replaced which promotes people`s dignity and privacy. The magnetic fire door closures have been fitted which ensures that people are fully protected in the event of a fire- taking place. Medication is being effectively recorded on the medication administration record, which ensures that people are protected by the medication administration procedures within the home. CARE HOMES FOR OLDER PEOPLE Reardon Court Cosgrove Close London N21 3BH Lead Inspector Wendy Heal Unannounced Inspection 10:00 14th July 2008 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.V364137.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Reardon Court Address Cosgrove Close London N21 3BH Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (If applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8447 9980 020 8350 4802 reardon.court@enfield.gov.uk www.enfield.gov.uk 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.V364137.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Nine of the 36 places are provided specifically for Intermediate Care in a separate dedicated flat. Nine of the 36 places are provided specifically for short-term respite care in a separate dedicated flat. One service user specified to the Commission and who is under the age of 65 may continue to be accommodated in the home until discharged. The Commission for Social Care Inspection must be informed as soon as that service user is discharged. The provider must undertake a programme of measures that will achieve full compliance with the National Minimum Standards for Older PeopleStandards 19-26 - Environment, or those equivalent standards that may be published at the time, as required by Regulation 23(1)(a); 23(2)(a to p); 23(4)(c) and Regulation 16(2)(c)(g)(j)(k) - by 1st October 2004. In order to promote the health and safety needs of service users living in Reardon Court. The provider must ensure that the home complies with all requirements contained in the relevant Health and Safety legislation and further must undertake a programme of measures that will achieve full compliance with National Minimum Standards for Older People - Standard 38 - Safe Working Practices, or those equivalent Standards that may be published at the time, as required by Regulation 23(1)(a); 23(2)(a to p); 23(4)(c) and Regulation 16(2)(c)(g)(j). One specified service user who is under 65 years of age may be accommodated in the home for respite care. The home must advise the registering authority at such times as the specified service user attains 65 years of age or vacates the home. One specified service user who is under 65 years of age may be admitted to the intermediate care flat for rehabilitation. The home must advise the registering authority at such time as the specified service user vacates the home. 4. 5. 6. 7. Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 5 Date of last inspection 10th July 2006 Brief Description of the Service: Reardon Court is a purpose built care home providing a service to elderly people. The service is divided into four flats or units, each providing a specific service. There are three units 11,12, and 29 were people stay permanently and have a diagnosis of dementia. Unit 30 provides respite care. Reardon Court also provides a range of other services such as a day centre, sheltered accommodation and an outreach service. Reardon Court is situated in a quiet, secluded residential area close to open land, transport links and the shops and services of Winchmore Hill. The Purpose and Function Document and Reardon Courts inspection report are available on the homes notice board. Reardon Courts fees are £69.65 pence per week. Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The rating for this service is good (2 stars) this means that the people who use the service receive good outcomes. This was an unannounced inspection and took place as part of the inspection process. Compliance was checked against key standards and took approximately 10 hours. The inspection started at 10am and finished at 8pm.We undertook a tour of the building. We spoke with people who live in the home and members of the staff team. We gained further information from the Annual Quality Assessment form and inspection of the documents kept in the home. This included care plans and health and safety documentation. The management team offered their assistance throughout the period of the inspection. We would like to thank the people who use the service and the management team for their openness and participation. What the service does well: A friendly flexible consistent service is provided with staff that is motivated to care for people using the service and promote its improvement. The manager and staff have a good relationship with people using the service, which ensures that people’s emotional wellbeing is maintained. The manager has updated the service user guide and statement of purpose. This ensures that up-to date information is available to people who may wish to use the service. People’s care plans in flats 11 and 12 are clear and up-to-date. This ensures people’s needs are met. People’s people’s relation being of health care records contained relevant information and indicated that health and wellbeing is promoted and protected. Procedures in to medication are good which further protects the health and well people living in the home. People are supported to exercise choice and control over their lives, which aids their self-esteem. People are provided with nutritious healthy meals, which ensures their dietary needs are met. Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 7 People who use the service their friends and relatives are listened to and complaints are taken seriously. A number of environmental improvements have taken place including the refurbishment of all the kitchens, which makes Reardon Court a nicer place to live. The home is clean and well maintained, which promotes people’s health and wellbeing. Staff are adequately trained to meet peoples needs. Professional recruitment procedures are in place, which protect people living and working in the home from potential abuse. Staff supervision is taking place regularly. This ensures that people can be supported in a professional consistent way. A quality assurance system is in place, which enables the view of the people using the service to be sought so that the service can monitor the quality of the service provided. The people spoken to who use the service speak highly in relation to the service they receive. What has improved since the last inspection? The refurbishment of the bathrooms and showers in all of the flats has been completed. The communal bathrooms are currently undergoing refurbishment. This means that people’s personal care needs can be fully met in a more appropriate environment. The laundry rooms in all of the flats are undergoing refurbishment and have been equipped with more up to date machinery, which works effectively. The flats have all been furnished with new dining room tables and chairs, which ensures that people have a comfortable place to eat their meals. The blinds in all of the flats at Reardon Court have been replaced which promotes people’s dignity and privacy. The magnetic fire door closures have been fitted which ensures that people are fully protected in the event of a fire- taking place. Medication is being effectively recorded on the medication administration record, which ensures that people are protected by the medication administration procedures within the home. Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 8 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. Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 9 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.V364137.R01.S.doc Version 5.2 Page 10 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): 1,2, People who use the service experience a good outcome in this area. This judgement has been made using available evidence including a visit to this service. People have the information they need to make an informed choice about were they want to live as a statement of purpose and service user guide was available. People are assessed before they are offered a service, which, ensures their individual needs can be met. EVIDENCE: At the time of the inspection the manager was in the process of updating the statement of purpose and service user guide. I have since been informed by the manager that these documents have now been updated and are currently in the process of being printed. The service user guide can be made available in large print and audio versions. The document can be translated into languages other than English and can be translated on request. The service also has a welcome pack and brochure, which the manager has also updated. Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 11 Since the previous inspection there have been a number of new admissions to the service this is due to the fact that a home has closed and a number of people transferred to Reardon court at the time of the homes closure. Inspection of the files indicated that assessments had been completed by the service. This ensures that people’s individual needs can be met. Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 12 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, People who use the service experience a Good outcome in this area. This judgement has been made using available evidence including a visit to this service. Not all of the care plans in specific units were being kept up-to-date. This does not assist staff to consistently meet people’s needs. Risk assessments are not always being kept up-to-date and do not always indicate how risks to people are being minimised. People are appropriately supported to ensure their health care needs are met. The recording of medication was completed effectively, which further safeguards people’s health and wellbeing. People’s rights are respected. This makes them feel valued. EVIDENCE: The care plans were inspected in flats 11,12,29,and 30.The care plans in flats 11,12, were clear to read. They evaluated all aspects of living in the home. The care plans identify people’s basic information, getting up, breakfast and morning routine, evening and night time routine, dietary requirements, communication, mobility, emotional support, health needs, medication and wishes in the event of a persons death. Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 13 The care plans highlight how people’s care is being carried out in line with their needs and wishes. One person likes to get up around 9 o’clock they like to get up slowly and “get their thoughts together” the person likes to dress themselves and then goes to the dining room for breakfast. This person likes a mid morning drink of milky coffee. Another person likes to shower each morning. This person uses a wheelchair but the care plan highlights how this person is encouraged to walk when in the safety of the flat. This person also has clear information regarding their specific condition, which is available for staff to read. The care plan had been reviewed and signed by the person the care plan was about and signed by the service manager. A number of new people had moved into flat 29 from a service, which has recently closed. Not all of the information is complete in all the specific areas of the care plans. However the management team have assured myself that the staff are in the process of completing these care plans to ensure they are as detailed as possible. A number of care plans in flat 30 need updating. Peoples specific needs appear to have changed and these changes need to be reflected in the current care plans. One person who needs two staff to support them during their personal care and used to need to have a bath outside the respite unit on a specific day. However they no longer have to do this because the bathing facilities in the respite flat have greatly improved. Staff are now able to meet the personal care needs of this person when they stay at the respite service. The care plans need to be more specific for example, one person’s care plan stated the person needs help with showering and bathing but does not indicate the type of help required. None of the care plans inspected indicated who the allocated keyworker was. This does not encourage the effective use of the key worker system for the benefit of the people using the service and the staff supporting them. The risk assessments to show potential risks for the identified people in flats 29 and 30 need to be reviewed and updated due to people’s changing needs. One person who has moved into flat 29 from another home, which has recently closed had information available which highlights the fact the person is prone to absconding. An up to date risk assessment was not available to indicate the fact that there is a coded entry system at the door of the flat to prevent free exit or entry to the flat, which minimises the potential risk of the person being able to abscond. We recommend that information is documented in people’s files to acknowledge that people’s freedom is being restricted and the reasons for this. This will ensure that clear information is available to all of the staff that support the people living in the home that the restrictions have been Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 14 agreed in the interest of the relevant people and that all appropriate professionals have agreed this. Evidence was seen that people are supported to meet their health care needs. People’s files inspected provided evidence that people are registered with a general practioner. The files identified a range of appointments, which included the dentist, district nurse, optician and chiropodist. However the people who use the facility of the chiropodist now have to pay a fee for this service. A district nurse was seen visiting one person on the day of the inspection. The doctor had also been called to the home to see a person the staff was concerned about. This ensures that the staff working at the home is safeguarding people’s health and wellbeing. I saw evidence that people had benefited from the hairdresser who carries out planned visits to the home. This promotes people’s self-esteem and makes People feel valued. The medication records were inspected and all of the information had been clearly signed for and recorded on the medication administration records. This helps to safeguard people’s health and safety. All of the people spoken with felt they were treated with respect. One person said, “You can’t get a better place than this”. People do have a key to their room, which they can choose to use to lock their bedrooms when they wish. We observed the interaction between the people living at Reardon Court and the staff that work there. The interaction witnessed between all the parties was affectionate, warm and appropriate. Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 15 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, People who use the service experience a good outcome in this area. This judgement has been made using available evidence including a visit to this service. The people’s lifestyle experienced in the home matches their expectations and preferences and satisfies their social cultural religious recreational needs which improves their quality of life. However activities are not recorded fully given changes in the day care services provided. People maintain contact with family members and friends, which benefits their emotional wellbeing. People exercise choice and control over their lives, which aids their self-esteem. People enjoy nutritious healthy meals, which ensures their dietary needs are met. EVIDENCE: We observed and were informed by the people living at Reardon Court and by the staff that work there that the activities that take place in the individual flats were based on people’s specific interests. These included listening to music, reading or listening to talking books that are brought to the home by the library service. The people at Reardon court also have their own pet cat, which they receive a great deal of pleasure from. However, the activities undertaken are not always recorded and were difficult to locate within some of the written records. This was discussed with one particular manager on the day Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 16 of the inspection. It was requested that all activities undertaken are recorded on an activity sheet showing what the activity was, who was involved in it. Also if a person declined to take part in an activity the action that was taken to encourage the person to take part in the activity. This will provide a clear record of activities undertaken this is very important due to the fact that the people who currently live in the residential flats are able to access Reardon Courts day services which offer a wide range of activities including games and creative activities. However people who are newly admitted to Reardon Court will no longer be able to use this facility. This is due to the number of people who are waiting to use this service from within the local community. Given this change we would like to be informed how it is proposed that activities are going to be provided to people living in the flats who are new to the service and what the planned arrangements for this are going to be. We had a conversation with a person and their relatives who were attending their relatives review and it was obvious that the service encourage family contact. This benefits people’s emotional wellbeing. The relatives and professional visiting the service said, “they were very happy with the care and support being provided at the home.” People are encouraged to exercise choice and control over their lives in relation to how personal care is offered and contact is promoted between people living at the home and their families. The people living at the home are provided with choice in relation to the food they eat which means their rights are respected. On the day of the inspection the kitchens in all of the individual flats were clean and tidy, which benefits the health and safety of people living and working in the home. The menu of food available was wholesome and nutritious and incorporated fresh fruit and vegetables, which ensures that people’s dietary needs are being met. The contents of the freezer and fridge were inspected. All food was identified as being within its use by date and had been stored correctly. This ensures people’s health is safeguarded. We observed the meals provided which were of a high standard and well presented. All of the people who were asked to comment on the food said, it was good. One person who worked as a butcher said, “the quality of the meat is excellent.” Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18, People who use the service experience a good outcome in this area. This judgement has been made using available evidence including a visit to this service. People who are living in the home can be confident that their views are listened to and acted upon since the recording and action taken in relation to complaints was found to be in order. Staff have received training and have the information available to protect people living in the home from potential abuse neglect and self-harm. EVIDENCE: Reardon Court has an adequate complaints procedure. This ensures people have the information available to enable them to make a complaint if they wish. We looked at the complaints file a number of complaints had been made at the time of the inspection, which the manager and their line manager had appropriately responded to. The time scales could be identified in relation to when the necessary action had been taken and all of the documentation was signed and dated which reassures people that their complaints are taken seriously and acted upon. The service has an up to date adult protection policy and procedure. The service also has Enfield’s multi agency adult protection procedure “You have the right not to be abused”. The service has a whistle blowing policy that was seen to contain guidance to staff on who they could communicate with if they believe the service is not Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 18 dealing appropriately with an identified situation, which provides added protection to people using the service and staff in relation to good practice being followed. There was evidence that staff had undertaken protection of vulnerable adults training. This ensures that the staff’s knowledge and skills are being kept-upto-date and this assists them to further protect people from potential abuse. Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 19 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): 19,20,21,24,26 People who use the service experience a good outcome in this area. This judgement has been made using available evidence including a visit to this service. People live in a safe well- maintained environment with safe comfortable indoor and outdoor facilities, which make Reardon Court a pleasant place to live. People have a sufficient number of bathrooms. The Bathrooms and toilets that have been recently refurbished to ensure people’s needs can be met. People living at Reardon Court have their own bedrooms, which are personal and suit their needs. Reardon Court is clean and hygienic which protects people’s health and safety. The respite unit is still to be refurbished. This will ensure that the environment is continuously improved. EVIDENCE: We completed a tour of the four separate flats. A number of environmental improvements have taken place since the last inspection. This included the replacement of the blinds in flats 11, 12, 29. This assists to ensure that people’s dignity and privacy is maintained. Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 20 Flat 11, 12, 29 and 30 have new dining room tables and chairs. This ensures people are able to eat their meals in comfort. The kitchens in all of these flats have also been replaced and up-to-date kitchen equipment obtained. This promotes a more homely environment. The bathrooms in flats 11, 12, 29 and 30 have now been refurbished completely. This provides people with a pleasant hygienic environment. The modernisation of the laundry rooms in flats 11 and 12 has started and new equipment has been obtained. The process has not been fully completed but the plan is for one laundry to be completed this year (as the units still need to be replaced and the laundry rooms need to be painted.) and the other laundry room to be completed next year. A number of further improvements need to be made. The lounge area of flat 30 needs to be redecorated. This should include the replacement of the carpet, armchairs which are worn and dated. The lighting also needs to be improved. This would provide a comfortable lounge for people to relax in. This would make all of the people staying for respite and the staff working at Reardon Court feels valued. The lobby areas that, includes the first floor lobby north wing and the corridor on the first floor near the staff room. The carpet near the first floor lift lobby on the south wing and the lobby area outside flats 29 and 30 need to be replaced as they are starting to look worn. This does not promote the service and give a good impression to people visiting the home for the first time. Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 21 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): 29,30, People who use the service experience good outcome in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are supported by qualified staff which means people’s needs can be met. People are safeguarded by the homes recruitment policies and procedures. EVIDENCE: During the inspection we looked at the rota and there was an adequate number of staff on duty to meet the needs of the people living there. There was a sufficient number of staff that had completed their NVQ level 2 or their NVQ level.3, which, ensures that staff are adequately trained to meet people’s needs. Staff had undertaken a range of training, which included the protection of vulnerable adults training. However some staff were due for refresher training and the manager is requesting that this training takes place. The documentation to indicate that staff on flat 30 had undertaken protection of vulnerable adults training was not available on the training system that is used to record this information. The manager has assured us that this training has taken place and will request that this information is recorded on the training record. Manual handling training, advanced person centred dementia care skills Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 22 training, safe handling of medication training had taken place. This further develops the staff’s skills to enable them to meet people’s needs. Staff recruitment policies and procedures and all relevant documentation were inspected and were found to be in order. This protects people living in the home from potential abuse. The supervision records of staff indicated that staff are receiving regular supervision. This means that staff are being supported to work with people living in the home in a consistent way. However we recommend that the supervision records in flat 30 are recorded in more detail to ensure that they are fully effective. This was discussed with the manager of the respite service who has agreed to record the information in more detail and acknowledged the importance of this. This is why a recommendation has been made on this occasion. Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 23 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): 31,33,36, 37,38, People who use the service experience a good outcome in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed by a stable competent management team. The views of people living at Reardon Court and their relatives are sought through a quality assurance system. Staff are appropriately supervised. Although records in flat 30 are not detailed enough. The health safety and welfare of people living in the home is taken seriously. EVIDENCE: The home is well managed by an experienced registered manager. He is supported by a skilled senior management team. The service is managed effectively. The senior managers have clear lines of accountability and areas of responsibility, which ensures they work with a professional approach. There is Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 24 a clear desire to develop the service and to respond to the needs of the people using the service. The quality assurance audit was last undertaken in 2007. The results in relation to the comments in the questionnaires are responded to and compiled into a report. The latest quality assurance survey is being undertaken by the service currently. This ensures that the views of the people using the service are taken seriously by the service. Supervision records were inspected. Staff do receive regular supervision. This means that a professional consistent approach is maintained to ensure the needs of the people using the service are met. A recommendation is made that the supervision documentation in flat 30 is more detailed. This will mean that the supervision process is as effective as possible for all of the people concerned. This was discussed with the manager of the respite service who acknowledged this matter and agreed to record information in more detail. This is why only a recommendation has been made on this occasion. The records of weekly fire alarm tests, and fire drills were inspected and found to be in order. All fire exits were clear and free from obstruction. This minimises the risk of harm to people in the event of the evacuation of the home. Doors have now been fitted with magnetic door closures. This ensures that people are effectively protected in the event of a fire-taking place. The service has completed a fire risk assessment. This means that professional practice is being followed. The company insurance was seen and found to be in order. The electrical certificate, portable appliance testing certificate was seen and found to be in order. This means that health and safety within the home is taken seriously. Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 X X 2 X 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 3 X 3 X X 2 2 3 Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 26 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 Timescale for action The Registered Person must 10/09/08 ensure that care plans are detailed and kept up-to-date. In relation to flat 29 all specific areas of the care plans must completed. This will ensure that detailed information is available in relation to the people who are new to the service. This will ensure people’s individual needs are fully met. The Registered Person must 10/09/08 ensure that the care plans are detailed, kept –up-to date and reviewed. With regard to flat 30 care plans must be fully detailed and up to date to reflect the changing needs of the people using the service. The care plans must be signed and dated and indicate the allocated key worker. This will ensure that people’s individual needs can be fully met. The Registered person must 05/09/08 ensure that risk assessments are kept up –to date and reviewed. The format used for recording risk assessments in flat 30 must include, risk areas, current DS0000033461.V364137.R01.S.doc Version 5.2 Page 27 Requirement 2. OP7 13 3. OP7 13 Reardon Court 4. OP7 13 5. OP24 23(2) 6. OP24 23 (2) 7. OP37 23 problems/issues, safeguards to be put in place, the date that the risk assessment was reviewed, the document must be signed and dated. This will ensure that the potential risks to the people living at Reardon Court have been minimised and the health and safety of people living and working in the home is promoted and protected. The Registered Person must ensure that the risk assessments are up to date. Care plans must reflect People’s changing needs in relation to flat 29. The person who is prone to absconding must have their risk assessment updated to reflect the fact that there is a controlled entry system on the flats, which has minimised this potential risk. The Registered Person must ensure that the carpets in the identified lobby areas are replaced. The Registered Person must ensure that the lounge area in flat 30 (Respite service) is decorated and the carpet is replaced. The lounge must also be refurbished with new armchairs side tables and more effective lighting. This will ensure people have a pleasant area to relax in during their stay. The Registered Person must ensure that an investigation is undertaken in relation to the inappropriate recording of information on the daily events record in the respite service flat 30. 05/09/08 20/12/08 20/11/08 05/08/08 Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 28 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 OP13 Good Practice Recommendations It is strongly recommended that activities are detailed and clearly recorded in all flats. We would like to be informed of how new people using the service are going to have their activity needs met given the current change in the day care arrangements. It is strongly recommended that the supervision records in flat 30 are recorded in greater detail to be fully effective. 2. OP36 Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Reardon Court DS0000033461.V364137.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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