Inspection on 14/12/06 for Adel Grange

This inspection was carried out on 14th December 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Adel Grange 05/11/07

Adel Grange 23/05/06

Adel Grange 15/12/05

Adel Grange 07/07/05

Adel Grange 27/01/05

Adel Grange 31/08/04

Adel Grange 20/04/04

Adel Grange 17/02/04

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

CARE HOMES FOR OLDER PEOPLE Adel Grange Adel Grange Close Leeds LS16 8HX Lead Inspector Carol Haj-Najafi Key Unannounced Inspection 14th December 2006 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 Adel Grange DS0000001405.V312309.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. Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Adel Grange Address Adel Grange Close Leeds LS16 8HX 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) 0113 261 1288 0113 2611288 Parkfield Healthcare Ltd Ms Hilary Preston Care Home 30 Category(ies) of Dementia - over 65 years of age (30) registration, with number of places Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd May 2006 Brief Description of the Service: Adel Grange is a converted, detached property situated in a residential area in Adel. There is a small area for car parking directly in front of the home. The home is located close to local bus routes. There are gardens to the rear and side of the property, which can be accessed by ramps. The home is registered to provide personal care for thirty older people with dementia. Accommodation is provided on three floors with some service areas located in the basement. A passenger lift links both floors, although one bathroom and bedroom can only be accessed by stairs. The accommodation consists of twenty single bedrooms, eight of which have en suite facilities, and five double rooms, three with en suite facilities. There are six communal bathrooms and two communal toilets. There are two lounges and a separate dining room. The kitchen is adjacent to the dining room. A notice in the entrance to the home states inspection reports is available on request. Fees for one week are £425. Residents and staff prefer the term residents, therefore this term has been used throughout the report. Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk. A pre-inspection questionnaire was completed by the home and this information was used as part of the inspection process. Comment cards were sent to residents and healthcare professionals and these responses have been included in the inspection report. Two inspectors carried out a site visit, which started at 9.30am and finished at 4.30pm. During the visit the inspectors looked around the home, observed staff and resident relationships, spoke to residents, staff and the registered manager. Some residents living at the home have difficulty communicating verbally and discussions with residents were limited, therefore observation of staff contact and communication was an important part of the inspection. Resident plans, risk assessments, healthcare records, health and safety records, and staff recruitment and training records were looked at. The last key inspection was carried out in May 2006. Following this inspection, the CSCI issued enforcement notices because they were concerned that the home was not providing a satisfactory service to the people living at the home. A Statutory Requirement Notice was issued in June 2006 and the home was told it must improve the standard of care by making sure; • • • Residents’ health and welfare needs are met Care plans and risk assessments identify how residents’ needs should be met Staff are recruited properly Inspectors carried out a random inspection in August 2006 to establish whether the home had complied with the Statutory Requirement Notice. This visit confirmed that the home had made good progress and had met all the requirements of the Statutory Notice. A random visit was also completed at the beginning of August and this was to look at a complaint received in relation to the standard of care provided at Adel Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 6 Grange. Most areas of the complaint were not upheld although it was identified that communication between management and staff needed to improve. This visit found that the home has continued to make significant progress and as a consequence the overall quality rating has changed to good. What the service does well: What has improved since the last inspection? What they could do better: The environment is generally well maintained but there were some maintenance issues identified. Staff have completed a lot of recent training but only 40 of care staff have National Vocational Qualifications (NVQ) awards. The national minimum standards recommend that at least 50 should hold the award. The recruitment process has generally been satisfactory but there were some areas where it should be more thorough. Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 7 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. Adel Grange DS0000001405.V312309.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 Adel Grange DS0000001405.V312309.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission’s process is good because the management team make sure the home can meet the resident’s needs before making a decision. EVIDENCE: Admission records for two residents were looked at. Each resident had assessments that identified the type of support they required. The manager and deputy co-ordinate admissions and complete the pre-admission assessments. Staff sign to confirm they have read the assessments before residents are admitted to the home. Information had been obtained from a previous placement for one resident. This information had been used when a new care plan and risk assessment had been written. Reviews were held a few weeks after admission. One review was held seven weeks after admission and the resident, relatives, a social worker and Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 10 representatives from the home attended. Everyone agreed that the home was suitable and they were happy with the care. A letter confirming the social worker had assessed the placement as suitable was on file. Residents had been given contracts when they moved into the home. The contracts had information about the terms and conditions and the fees that applied. The home does not provide intermediate care. Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments are good and residents’ needs are properly monitored. The home has good systems in place to make sure residents receive the right support from healthcare professionals. EVIDENCE: Four care plans were looked at. Care plans had been divided into twelve sections. Each section had been completed in sufficient detail and reflected the needs of the resident. The plans were very specific to each resident and there was clear guidance on how their individual needs should be met. For example ‘hand clothes one by one and he will dress himself, ask questions he can answer yes or no, when talking make sure you are facing her and gain eye contact’. During the past six months care plans had been reviewed at least once a month. Staff had signed a sheet at the front of each file to confirm they had read the care plans. A new member of staff said she had read the plans and felt they had given her enough guidance to understand how she should support Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 12 individual residents. Staff talked about how they supported residents and this was reflected in the care plans. Residents or their representatives had signed the care plans to confirm they agreed with the contents. The manager had met with a number of relatives to discuss the care planning process. Information that was in pre-admission assessments had been transferred into care plans and risk assessment. Each resident had a ‘my life’ booklet that provided details of life history, which had been completed by residents and their relatives. Current information was transferred to care plans. This is good practice because it demonstrates that the care planning process covers all aspects of a person’s needs. Risk assessments for four residents were looked at. All the risk assessments were good and had been reviewed. All residents had a range of assessments that generally covered the key areas of need. Risk management plans were in place that identified how potential risks should be managed. Residents’ weight had been regularly monitored and a record was maintained. Weight gains and losses were recorded. One resident had started losing weight, and as soon as this was identified, a daily food chart to monitor food intake was started. Staff gave examples when dieticians had been involved because staff were concerned. Nine GP comment cards were returned. Eight stated they were satisfied with the overall care. One left it blank but added, limited knowledge of all aspects of care. Residents were registered with a GP and a referral was made to the local dental practice as soon as they were admitted to the home. Daily records stated that residents had attended healthcare appointments within the last four weeks. Daily records also identified where concerns had been raised about the health of residents and the action that had been taken. For example one resident had a problem with their ear and staff had contacted a GP the same day, another resident was having problems with their legs and again the GP was contacted. Medication that had been prescribed by the GP was obtained promptly. One resident had been prescribed support tights. She was wearing the correct tights and staff confirmed that she wears them daily. Each resident had a significant events record, which summarised events, and these confirmed that residents had received regular healthcare. Staff were seen to check that a resident was sat on a pressure-relieving cushion Incident records were completed with good detail, and reasons why accidents and injuries occurred were explored. Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 13 Medication systems were looked at. The medication administration records had details of residents preferred names, instructions for administration were specific and codes were used correctly. Audits of medication ordering and administration were looked at and these were all correct. No large stocks of medication were held on site. All staff who administer medication had completed medication training. The manager had completed regular medication audits. Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. The quality of care has vastly improved and residents have a better lifestyle. They have more opportunities to engage in meaningful activities, this should continue to be developed to make sure they are motivated throughout the day. EVIDENCE: Inspectors spent most of the day in communal areas and spoke to residents, staff and the manager. Staff relationships with residents were very good. Staff were seen to be very discreet when asking residents to go to the toilet. One resident described the staff as lovely. The general atmosphere was very relaxed and residents were comfortable and content. The appearance of residents was good, they were dressed appropriately and attention had obviously been given to their personal care. For example, residents’ hair had been brushed and their glasses, shoes and clothing were clean. Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 15 Daily records had times when residents had gone to bed and got up. Some residents were going to bed at midnight, others were going earlier, and times for getting up were also varied. Staff said that routines were flexible. Two residents that spend a lot of time in their room said staff regularly come and visit them. One uses her call system when she is ready for a hot drink. Four comment cards were received from residents. They were generally positive about the home. Three gave varied responses for making decisions about what to do. One stated everyday seems the same. Staff talked about recreational activities and said the weekly arts and craft session and a motivation group both of which are run by external facilitators were very good. The motivation group was held on the afternoon of the inspection and residents were enjoying this session. A Carol concert was planned for the day after the inspection and a Christmas party was planned for the following week. Daily records stated that residents had been out with staff on shopping trips and to a local nativity play. There were also details of visits from relatives, personal care and hair appointments. There wasn’t much information about what residents were doing on a daily basis unless there was an organised activity. Staff and the manager agreed this was area that could be further developed. Staff made sure they observed residents and gave assistance when it was required. However, they appeared to do this in a supervisory way rather than engaging with residents. As the level of daily activity develops the level of engagement should also increase. The manager said she had been exploring options to increase the opportunities for residents to engage in religious observances. A pastor from a local church had made a recent visit and a priest was due to visit the day after the inspection. Lunch was a sociable occasion which residents appeared to enjoy. Residents said the food was good and it was always hot. The dining room was not set until just before lunch, which is good because then residents don’t get confused about meal times. Staff were well organised and each resident was offered a choice of meals. Four weeks menus were sent with the pre inspection material and these were varied and nutritious. The meal served corresponded with the menu. Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory procedures are in place to safeguard residents and staff are aware of how and where to report any concerns. EVIDENCE: The pre-inspection questionnaire stated that the home had a complaint procedure and an adult protection procedure. The complaints procedure and a whistle blowing policy were displayed in the home. A new member of staff said they went through the whistle blowing policy as part of the induction. Staff have attended adult protection training. Since the last key inspection in May the Commission has received two formal complaints. One complaint was investigated by the registered provider and resolved satisfactorily and the Commission looked into the other. The complaint which was looked at by the Commission alleged that the standard of care was not satisfactory and residents were being man-handled, they also alleged there were problems with recording systems, medication, the environment, cleaning products and staff training. Sixteen staff were interviewed and this included the manager, senior staff, care staff, domestic and catering staff, and the registered provider. Although most areas of the complaint were not upheld, it was evident there was a fundamental communication problem. Following the investigation, the manager and Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 17 registered provider held a staff meeting and discussed communication systems with the staff team. Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 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 home is pleasant, well maintained and residents are very comfortable in their surroundings, staff try to make it is a ‘nice cosy place to be’. EVIDENCE: A tour of the building was carried out. All bedrooms, communal areas and bathrooms were visited. The home was clean and tidy and there were no odours. Decoration, furniture and furnishings were of a reasonable standard. Fire equipment was tested in March 2006. Several areas had recently been decorated and new lighting had been fitted in the lounge, dining room and entrance. Bedrooms were personalised and some residents had brought items when they moved in, which included standard lamps and clocks. Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 19 Previously there have been problems with the heating and hot water. The manager and staff confirmed this had been resolved and the home was always warm enough. Throughout the home there were supplies of wipes, hand wash, aprons and thermometers for testing the temperature of bath water. The manager said she had a programme of decoration and anticipates any internal rooms that have not been decorated will be done in the next few months. She agreed to send a copy of the programme to the Commission. There were some minor things that needed attention and these are; • • • • • • • • • Some doors were not closing properly Some rooms did not have a piece of lockable furniture Screening in a double room should be extended Debris on the flat roof needs removing Guttering near the kitchen needs cleaning Guttering at the front of the house was broken The grate over the basement window was tilted The steps to the basement should have restricted access The external paintwork needs attention Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are far more equipped and skilled to provide good care. They have a better understanding of their roles and responsibilities. Staff morale has improved and everyone has started working as a team. EVIDENCE: The manager has changed the staff-working pattern. Staff work longer shifts but have more days off. There are now two teams that work opposite each other. Staff said this had helped build better teams and everyone was working well together. An employee of the month award had also been introduced. Staff said the morale is better and they know what they are doing. In June 2005, the registered provider agreed with the Commission to limit the number of residents living at the home to 22 because the home had consistently failed to meet the National Minimum Standards and the Care Homes Regulations. This inspection confirmed that the home had made a lot of progress and was generally meeting the required standard. Therefore it was agreed with the manager that it was appropriate to start increasing the number of residents up to the registered number of 30. Currently three carers and a senior work during the day and the manager and deputy are also available, although the deputy often covers the senior role. The manager agreed to ensure staffing levels are reviewed as the number of Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 21 residents increases and she anticipated that an additional member of staff would be required for each shift, and herself and the deputy would be supernumerary. Recruitment records for two staff were looked at. All the relevant information had been obtained although there was a gap in the employment history on one application form. Two references had been obtained for both candidates but the manager agreed to try to obtain a more formal reference for one candidate. Interview notes were available and these confirmed that the candidates had talked about their past experience. The manager had explored historic details that had been raised as an issue but this information had not been recorded. There should have been a record of this discussion. Two staff talked about the recruitment process and confirmed that they attended an interview. One staff confirmed she had an induction when she started. One person who was waiting to start employment was spending some time at the home because she had never previously worked in the care field; she confirmed the manager had suggested this. Staff training records were looked at. These confirmed that all staff had completed a range of training courses. Training included, dementia, challenging behaviour, first aid, medicine administration, fire training and moving and handling. The pre inspection questionnaire stated that 40 of care staff had completed their NVQ level 2 awards. The national minimum standards recommend a minimum ratio of 50 . Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home is much better and this has resulted in a vast improvement in the standard of care at Adel Grange. EVIDENCE: The manager started work at the home in May 2006 and was registered with the Commission in August 2006. She is a qualified nurse and has completed the registered manager’s award. The manager talked about her role and responsibilities and had a clear vision of how she will continue to move the home forward. Staff at the home talked about the changes that had taken place over the last six months. All staff said residents were getting a better service. Comments Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 23 included, ‘the running of the home is more focused, I feel more confident, we’re moving in the right direction, there has been a real big difference with staff attitudes, everyone is working together, we understand care plans now, the care is focused on what is needed, the management is good.’ The manager has introduced formal supervision and all staff have had at least three supervision sessions with her since June. Relative surveys have recently been developed and the manager was planning to send these out in the near future. They ask for comments on staff, the environment and personal care. The pre inspection questionnaire stated that policies and procedures were available and regular maintenance and health and safety checks by external agencies were completed at the home. The medication policy was looked at during the inspection. The manager said relatives or solicitors managed residents’ finances. Regular checks are carried out around the building and these are recorded. The records confirmed that fire systems, water temperatures, cleaning equipment and general lighting were checked. This is good practice because health and safety problems have been identified as they arise and generally dealt with promptly. Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 24 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 3 3 3 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 2 3 3 3 X 3 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 25 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 OP19 Regulation 23 Requirement The registered person must complete the maintenance work that has been identified in the main body of the report. A copy of the redecoration programme should be forwarded to the CSCI The registered person must ensure at least 50 of care staff have NVQ level 2 or equivalent The registered manager must ensure any gaps in employment history have been explored. Timescale for action 31/03/07 2. 3 OP28 OP29 18 19 31/08/07 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations The registered person should continue to develop the programme of activity. Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Adel Grange DS0000001405.V312309.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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