Inspection on 06/05/08 for Grace House

This is the latest available inspection report for this service, carried out on 6th May 2008.

CSCI found this care home to be providing an Good service.

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

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Grace House 110 Nether Street Finchley London N12 8EU Lead Inspector Daniel Lim Key Unannounced Inspection 6th May 2008 9:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Grace House DS0000069354.V362546.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. Grace House DS0000069354.V362546.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grace House Address 110 Nether Street Finchley London N12 8EU 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) 0208 4455628 0208 4455628 anngilbertcct@aol.com Christian Care Trust - Board of Trustees Ann Veronica Gilbert Care Home 10 Category(ies) of Dementia (10), Mental disorder, excluding registration, with number learning disability or dementia (10), Old age, of places not falling within any other category (10) Grace House DS0000069354.V362546.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP Dementia - Code DE 2. Mental Disorder, excluding Learning Disability or Dementia - Code MD The maximum number of service users who can be accommodated is: 10 24th April 2007 Date of last inspection Brief Description of the Service: Grace House is a small care home registered in February 2007 to provide personal care for a maximum of ten older people with either dementia, mental health problems or healthcare problems associated with old age. It is run by a charity called The Christian Care Trust. The stated aim of the home is to provide high quality care in a homely and Christian environment. The home was opened following the voluntary closure of the former Grace House (53 Clifton Road, Finchley, London N3 2AS). All staff and one resident transferred into the new home. The home is a detached three, storey house with eight bedrooms for residents. On the ground floor is located the office, laundry, dining room, kitchen, lounge, a communal bathroom with a toilet and two bedrooms. On the first floor are six bedrooms for residents. The manager’s accommodation is located on the second floor. Grace House DS0000069354.V362546.R01.S.doc Version 5.2 Page 5 The home has no chair lift or shaft lift. Therefore, those with mobility problems must not be accommodated on the first floor. There is a small parking area at the front of the house and a large garden at back. The gardens are attractive and accessible to service residents. There is a patio at the back of the home. The home is situated in a residential area and about half a mile from shops, restaurants, public transport and other community facilities located along Ballards Lane. There is an underground station nearby. The Trust also operates a registered domiciliary care agency from the same building. The fee charged by the home is £750 - £910 per week. The home manager is Mrs Ann Gilbert. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Grace House DS0000069354.V362546.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. This inspection was carried out on 6 May 2008 and took a total of seven hours to complete. A second visit was made on 7 May 2008 to view documents not available on the first day. During this inspection, the inspector was accompanied by the senior carer and the home manager (Mrs Ann Gilbert). Four residents were interviewed. They indicated that they were well treated and satisfied with the services provided. Completed questionnaires were received from 3 residents, 2 relatives, and a healthcare professional. The feedback received from all was positive and indicate that the respondents were satisfied with the care provided at the home. Statutory records including the maintenance records, accident book, fire log book and residents’ case records were examined. These were on the whole, well maintained. The premises including bedrooms, bathrooms, lounges, laundry, kitchen, garden and communal areas were inspected. These areas were clean and tidy. Five staff on duty were interviewed on a range of topics associated with their work. They were noted to be knowledgeable regarding their roles and responsibilities. Staff records, including the staff rota, supervision records, evidence of CRB disclosures, references and training records were examined. The completed Annual Quality Assurance Assessment form (AQAA) was received by CSCI. Information provided in the assessment was used for this inspection. What the service does well: Residents, relatives and a healthcare professional provided positive feedback and indicated that residents were provided with a high standard of care. This was confirmed in a recent survey conducted by the home. Staff are carefully selected and they were noted to be respectful and responsive towards residents. The home is homely, clean and well maintained. It is furnished to a high standard. The communal rooms are spacious and cheerfully decorated. Grace House DS0000069354.V362546.R01.S.doc Version 5.2 Page 7 The meals provided are of a high standard and residents were satisfied with the food provided. What has improved since the last inspection? What they could do better: Improvements are required in the care arrangements of residents. The care plans of residents must be comprehensive and address the social, cultural and spiritual needs of residents. This is to ensure that the holistic needs of residents are attended to. The care plans of residents must be signed either by them or their representatives. This is to ensure that residents or their representatives are aware and are in agreement with the plans prepared. The care plans of residents must be reviewed monthly. This is to ensure that the care plans provided are up to date and reflect changes in the condition and care needs of residents. Improvements are required in the staffing arrangements. Evidence that staff have been provided with training in Adult Protection must be provided. This is to ensure that staff are fully informed of their roles and responsibilities. A risk assessment must be carried out regarding the manager’s daily on call arrangements during the night shift. This is for health and safety reasons and to ensure that the needs of residents are met. Residents (or their representatives) must be consulted regarding the management of the home. Documented evidence of this must be available for inspection. This is to ensure that residents are well cared for and their preferences are responded to. Grace House DS0000069354.V362546.R01.S.doc Version 5.2 Page 8 An independent report into the appropriateness of the use of the “stair crawler” in the home for transporting residents up the stairs must be arranged. This is to ensure the safety of residents. The fire alarm must be tested weekly and a record kept of weekly tests carried out. This is to ensure the safety of residents in the home. 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. Grace House DS0000069354.V362546.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 Grace House DS0000069354.V362546.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): 3, 6 People using this service experience good outcomes in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The home has developed a comprehensive Statement of Purpose which is specific to the resident group and considers the different styles of support and care required to meet the needs of people who use the service. Admissions are not made to the home until a full needs assessment has been undertaken by the manager or a sufficiently skilled member of staff. EVIDENCE: The four residents who were interviewed informed the inspector that they were well cared for and their care needs had been attended to. This was reiterated in completed questionnaires received by the inspector. Grace House DS0000069354.V362546.R01.S.doc Version 5.2 Page 11 Comments made by residents included, “l am satisfied with care provided”, “well cared for”, “nice staff” and “well treated by staff”. Residents in the home were noted to be clean and appropriately dressed. A sample of three residents’ case records which was examined contained assessments. These assessments were comprehensive and informative regarding the care needs of residents. Risk assessments had also been carried out. Following a requirement made in the last inspection report, the statement of purpose had been updated and included the required items. The manager stated that the home does not provide intermediate care. Grace House DS0000069354.V362546.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 using this service experience good outcomes in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements in place for ensuring that the healthcare and personal care needs of residents were on the whole satisfactory. Personal and healthcare needs including specialist health and dietary requirements are recorded in each resident’s plan and they give a clear view of the healthcare needs of residents. EVIDENCE: Residents interviewed stated that they were well cared for and they had been treated with respect by staff. They indicated that their healthcare needs had been met and they could see a doctor if they needed to. A healthcare professional who sometimes visited the home was able to confirm in her completed questionnaire that residents’ healthcare needs had been attended to. She stated, Grace House DS0000069354.V362546.R01.S.doc Version 5.2 Page 13 “ The home provides constant attention and care to each person as their needs dictate. This is one of the best care homes I have encountered”. The sample of three case records examined were structured and neat. Following a requirement made in the last inspection report, the care plan of a resident with nutritional problems now contained a nutritional care plan. This ensures that staff and the resident concerned are provided with appropriate guidance regarding the dietary arrangements. The care plan of a resident assessed as being at risk of developing pressure sores contained an appropriate pressure area care plan. The manager indicated that staff had been vigilant in ensuring that she does not sit in one position for too long. She further added that due to the care provided, this resident had not developed any pressure sores. However, further improvements are needed in the care arrangements as the case records examined did not contain cultural, social or spiritual care plans. These are needed to provide evidence and ensure that the cultural, social and spiritual needs are being attended to. The manager, reassured the inspector that residents are nevertheless, supported in these areas. She agreed that these care plans would be prepared. The care plans examined had not been signed by either residents or their representatives. The senior carer stated that she was unaware that this needed to be done. These care plans must be signed to indicate that residents or their representatives are aware of the plans and are in agreement. Some reviews of care had been carried out. However, these had not been recorded monthly. Reviews must be carried out monthly and recorded to ensure that the care plans provided are up to date and reflect changes in the condition and care needs of residents. The temperature records of the room where medication was stored had been recorded daily. These were satisfactory and no higher than 25C. The medication charts were examined. These indicated that medication had been administered. The inspector however, noted that one of these charts had a couple of blank spaces and staff had not indicated if medication had been administered. This was brought to the attention of the senior carer. She informed the inspector that the food supplement concerned was not required daily and it was therefore left blank. She agreed to indicate on the chart that this was the case. This was done during the inspection. Examples of good practice were given. The manager informed the inspector that the home had been successful in assisting two residents make dramatic improvements in their health. One related to a resident who was physically very unwell and another related to a resident who was physically and mentally unwell. She stated that both residents were now in a better state of health Grace House DS0000069354.V362546.R01.S.doc Version 5.2 Page 14 than previously. One of the residents concerned was able to provide confirmation that his health had improved since coming to the home. Grace House DS0000069354.V362546.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 using this service experience good outcomes in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The daily life, meal arrangements and routines of residents were on the whole, well organised. People using the service are given the opportunity to take part in activities both within the home and in the community. They also have opportunity to maintain important family relationships. Residents and their representatives expressed satisfaction at the service provided. EVIDENCE: The home had a varied programme of weekly social and therapeutic activities. The programme which was available for inspection included exercise sessions, religious worship sessions, special lunch sessions for residents with their friends, walks, art, massage sessions and outings. The manager stated that all residents of the home have Christian affiliations and and staff are willing to take them to church services. Grace House DS0000069354.V362546.R01.S.doc Version 5.2 Page 16 The four residents interviewed were of the opinion that the activities were appropriate. They further confirmed that they had been able to maintain relationships with the relatives. This was confirmed in completed questionnaires received and in correspondence available for inspection. The bedrooms inspected had been personalised by residents with their personal items such as photos, cards, pictures and souvenirs. Residents indicated that staff were responsive towards them and they were well cared for. The kitchen was clean and well equipped. The menu appeared varied and balanced and reflected the ethnic composition of the residents of the home. The chef had worked in the home for several years and was knowledgeable regarding the meal preferences of residents. The manager stated that food is freshly prepared in the kitchen each day. Although there were no residents from an ethnic minority, the manager reassured the inspector that if necessary, ethnic meals can be provided. Residents interviewed indicated that they were satisfied with the meals provided. A record of fridge and freezer temperatures had been kept. These were satisfactory. Grace House DS0000069354.V362546.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 using this service experience good outcomes in this area This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements for responding to complaints and for adult protection was on the whole, satisfactory. The required polices and procedures for safeguarding residents were in place and give clear and specific guidance to staff. EVIDENCE: The four residents who were interviewed indicated that they were well treated and they knew who to complain to if they were dissatisfied with the care provided. The home had an adult protection procedure. It included information on examples of abuse and guidance to staff on reporting allegations of abuse to Social Services and The CSCI. The manager and her staff who were interviewed were aware of the home’s policy and procedures of the protection of vulnerable adults. There was evidence that they had been provided with the required training. No complaints had been documented in the complaints book since the last inspection. The senior carer explained that none had been received. The issue of equalities and diversity was discussed with the manager and staff. Staff indicated that they had been instructed to treat all residents sensitively Grace House DS0000069354.V362546.R01.S.doc Version 5.2 Page 18 and with respect regardless of disability, gender, race, religion or sexual orientation. The home had an equalities and diversity policy. The home had a record of compliments received. These indicated that relatives of residents thought highly of staff and were grateful for the care provided by the home. Comments made included the following: “ Thank you for the great welcome you gave…and for the care .” “Thank you for looking after my mum.” and “I have found Grace House a very caring environment.” One staff member stated that she had not received adult protection training and training certificates were not available for some staff. A requirement is therefore made in the section on “Staffing” for evidence of training in adult protection to be provided. Grace House DS0000069354.V362546.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, 23, 25, 26 People using this service experience good outcomes in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The home was clean and furnished to a high standard. Residents are allowed to personalise their bedrooms. Overall, the home provides a pleasant and attractive environment to live in. Residents were pleased with their accommodation. EVIDENCE: Residents interviewed stated that they were happy with the accommodation provided. The premises appeared cosy, well furnished and the décor was of a high standard. All bedrooms have ensuite facilities. They had been personalised by residents with their own souvenirs and memorabilia. Furniture Grace House DS0000069354.V362546.R01.S.doc Version 5.2 Page 20 provided in the lounges were comfortable and of a good quality. There was a large lounges and a dining room. All areas of the home were clean. Specialist equipment available in the home included a portable hoist, a “staircrawler” and several wheelchairs. The “staircrawler”chair is an electric chair capable of climbing the stairs. We discussed the equipment’s safety record and appropriateness for residents with the manager. In view of the concern, a requirement is made for an assessment to be made by an occupational therapist or suitably qualified professional. The back garden was attractive and well maintained. Vegetables were being grown at the end of the garden. The senior carer stated that they would be used in the home. Grace House DS0000069354.V362546.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): 27, 28, 29, 30 People using this service experience good outcomes in this area This judgement has been made from evidence gathered both during and before the visit to this service. People who use the service have confidence in the staff who care for them. The staffing levels were adequate and staff were closely supervised. The service has a good recruitment procedure that is followed in practice. EVIDENCE: Staff who were on duty were interviewed on a range of topics associated with their work. They were generally knowledgeable regarding their roles and responsibilities. They stated that they had been instructed to treat all residents with respect and dignity regardless of their race, religion or sexual orientation. Residents who were interviewed indicated that staff were respectful and they had not been ill-treated. The duty rota was examined. There was normally three care staff on duty during the day shift and one care staff on duty during the night. The manager was on call every night. This night staffing and on call arrangement was discussed with the manager and her staff. They stated that the staffing Grace House DS0000069354.V362546.R01.S.doc Version 5.2 Page 22 arrangements were adequate. The manager stated that she was rarely disturbed and no problems were encountered. However, to ensure that the needs of residents are met during the night shift and the manager has sufficiently rest, a requirement is made for a risk assessment to be carried out. The manager agreed that this would be done. The training records examined, indicated that staff had been provided with most of the required training. There was evidence that staff had been provided with training in Moving and Handling. The certificates were available for inspection. Not all records examined contained evidence that staff had been provided with adult protection training. One staff member stated that she had not received adult protection training. The manager indicated that most of her staff had been provided with adult protection training. Recruitment records examined indicated that the required recruitment procedures (including obtaining of satisfactory CRB disclosures and references) had been followed. Supervision records examined indicated that staff had been provided with regular supervision. Evidence of annual staff appraisals was also available for inspection. Grace House DS0000069354.V362546.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, 35, 38 People using this service experience good outcomes in this area This judgement has been made from evidence gathered both during and before the visit to this service. People living in the home can be assured that the home is generally well run. The manager has skills and ability to deliver a good quality of care. Residents are consulted. However, evidence of this should be made available. EVIDENCE: The registered manager had obtained her RMA and was knowledgeable regarding the needs of residents. Grace House DS0000069354.V362546.R01.S.doc Version 5.2 Page 24 The fire records and fire log book were examined. Fire drills and fire training had been organised for staff. However, the weekly fire alarm tests had not been documented for the past 4 weeks. The senior carer explained that she had carried them out weekly but forgotten to sign the log book. This was confirmed by the manager. The senior carer promptly completed the fire log book the next day. (The manager also confirmed that the fire alarm had been tested soon after the inspection by her and it was in working order). The home had a fire risk assessment which had been updated recently. Safety inspections had been carried out on the portable appliances, hoist, gas installations and electrical installations. Window restrictors had been provided in bedrooms inspected. A current certificate of insurance was displayed. The management of residents’ finances was discussed. The inspector was informed by the manager that the home does not manage or keep any money on behalf of residents. The inspector was provided with the results of a recent consumer survey and the subsequent report. This was positive and indicated that respondents were very satisfied with the care provided. No adult protection issues had been raised in the past year. The manager however, reassured the inspector that if any did occur, the lessons learnt from safeguarding findings would be incorporated into the management of the home and care of residents. No minutes of regular meetings with either residents or residents’ representatives had been documented. These are needed as evidence that residents are fully consulted and informed regarding the management of the home. The manager explained that informal discussions had taken place. She agreed that documented evidence of future consultations would be provided. Following a requirement made in the last inspection report, minutes of formal meetings with staff had been documented. Grace House DS0000069354.V362546.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 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 X 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Grace House DS0000069354.V362546.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 12(1) 15(1) Requirement The care plans of residents must be comprehensive and address the cultural, social and spiritual needs of residents. This is to ensure that the holistic needs of residents are attended to. 2 OP7 12(1) 15(1) 30/06/08 The care plans of residents must be signed either by them or their represenatives. This is to ensure that residents or their representatives are aware and are in agreement with the plans prepared. 3 OP7 12(1) 15(1) 30/06/08 The care plans of residents must be reviewed monthly. This is to ensure that the care plans provided are up to date and reflect changes in the condition and care needs of residents. Grace House DS0000069354.V362546.R01.S.doc Version 5.2 Page 27 Timescale for action 30/06/08 4 OP27 13(4)(c) 18(1)(a) A risk assessment must be carried out regarding the manager’s daily on call arrangements during the night shift. This is for health and safety reasons and to ensure that the needs of residents are met. 24/06/08 5 OP28 18(1)(a) (c) 01/08/08 Evidence that staff have been provided with training in Adult Protection must be provided. This is to ensure that staff are fully informed of their roles and responsibilities 6 OP33 16(2)(m) Residents (or their representatives) must be consulted regarding the management of the home Documented evidence of this must be available for inspection. This is to ensure that residents are well cared for and their preferences are responded to. This requirement is restated and reworded. The previous unmet timescale was 13/07/07 30/06/08 7 OP38 23(4) An independent report into the appropriateness of the use of the “stair crawler” in the home for transporting residents up the stairs must be arranged. This is to ensure the safety of residents. 13/06/08 Grace House DS0000069354.V362546.R01.S.doc Version 5.2 Page 28 8 OP38 23(4) The fire alarm must be tested weekly and a record kept of weekly tests carried out. This is to ensure the safety of residents in the home. 01/06/08 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 Grace House DS0000069354.V362546.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 Grace House DS0000069354.V362546.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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