Inspection on 10/11/05 for Autumn Grange Care Home

This inspection was carried out on 10th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Autumn Grange Care Home 15/12/08

Autumn Grange Care Home 02/10/08

Autumn Grange Care Home 30/06/08

Autumn Grange Care Home 15/08/07

Autumn Grange Care Home 23/11/06

Autumn Grange Care Home 04/04/06

Autumn Grange Care Home 18/08/05

Autumn Grange Care Home 16/06/05

Autumn Grange Care Home 24/02/05

Autumn Grange Care Home 15/09/04

Autumn Grange Care Home 04/02/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Autumn Grange Care Home 19-29 Herbert Road Sherwood Rise Nottingham NG5 1BS Lead Inspector Susan Lewis Unannounced Inspection 10th November 2005 10:00 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 Autumn Grange Care Home DS0000002190.V265956.R01.S.doc Version 5.0 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. Autumn Grange Care Home DS0000002190.V265956.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Autumn Grange Care Home Address 19-29 Herbert Road Sherwood Rise Nottingham NG5 1BS 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) 0115 8417475 0115 9620061 Mr Munchi Khan Nora Gazeley Care Home 72 Category(ies) of Dementia - over 65 years of age (49), Old age, registration, with number not falling within any other category (23) of places Autumn Grange Care Home DS0000002190.V265956.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Registered Manager must be full time and have full time supernumery hours of work Two Senior Carers to be in charge, one on each unit(two in total) from 08:00-20:00 for 72 service users at least 7 (seven) care assistants must be provided from 08:00-20:00 Date of last inspection Brief Description of the Service: The home is located in a quiet residential area of Nottingham (Sherwood Rise) with access to local amenities. The city centre of Nottingham is about 1 mile away and there is a direct bus route to and from the city centre with a bus stop about 300m metres from the care home. A park and ride service is available, about 500 metres from the care home. The home is split into three units, two of which provide up to forty-nine (49) places for people who may have a Dementia related illness (residential, non-nursing). The other unit provides personal care (residential care, non-nursing) for up to twenty-three (23) older people. The home provides a reasonable standard of accommodation for service users. There is a choice of lounges and combined dining room areas, all in reasonable decorative condition. The building is wheelchair accessible with adaptations and equipment appropriate to the needs of the service users. The garden area to the front of the premises has been reconfigured, with an enclosed safe garden being created to enable service users to use. Parking is limited, but on the road parking is available only several metres from the front entrance. The manager has considerable experience in the caring field and the staff team have a sound knowledge of the service user group and of the needs of the individuals who live in the Care Home. Autumn Grange Care Home DS0000002190.V265956.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was third unannounced inspection carried out on this home during this inspection/financial year and took place over seven hours. It was partly carried out with the Environmental Health Officer Steve Matthews from Nottingham City Council. A partial tour of the building took place and a selection of bedrooms and communal areas were viewed. Staff and care records were inspected and staff and residents were spoken with. The manager was unavailable during the inspection and the deputy manager was available throughout the day for discussion and feedback. What the service does well: What has improved since the last inspection? A deputy manager has now been employed as previously recommended during inspections. The requirements set following the serious outbreak of diarrhoea have now been met. A bathroom has been refurbished and is now a shower room. What had been the old physiotherapy pool has now been successfully altered to be two new ensuite bedrooms. The new registration will be 74 and the home is awaiting its certificate to confirm this. The conditions will be amended to show the increase of registration. This will be amended on the next report. Autumn Grange Care Home DS0000002190.V265956.R01.S.doc Version 5.0 Page 6 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. Autumn Grange Care Home DS0000002190.V265956.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Autumn Grange Care Home DS0000002190.V265956.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 4 and 5 Prospective residents are able to visit the home prior to moving in if they so wish. All newly admitted residents have care plans created within 48 hours of their arrival. EVIDENCE: An immediate requirement was set at the inspection on 16th June 2005 regarding the welfare of service users and to ensure that where residents are identified as being at risk of dehydration that proper provision is made and monitored. Care plans viewed provided evidence that this was being met. There was evidence that where residents needed the input of specialist support such as psychiatrists and community psychiatric nurses that this was available. One resident’s care plan identified a cultural need but on further investigation it was clear that this need was not being met because the person in question was not particularly bothered. Autumn Grange Care Home DS0000002190.V265956.R01.S.doc Version 5.0 Page 9 This needed to be recorded. New residents spoken with said that although they had not had opportunity to visit the home prior to moving in their relatives had and had discussed the move and what the home was like. None of the residents whose care plans were viewed and were newly admitted had been emergency admissions, all residents had care plans created within 48 hours of their moving to the home ensuring staff knew how to meet their needs. Autumn Grange Care Home DS0000002190.V265956.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 11 Work in improving care plans is ongoing. Procedures in receiving, recording and administering medication have the potential to place residents at risk. EVIDENCE: Four care plans were viewed as part of this inspection. The new deputy manager is involved in looking at improving the content within the care plans. This is an ongoing process as the deputy manager has only been in post approximately 6 weeks. A requirement was set at the inspection on 16th June 2005 regarding the level of detail in care plans. Some of the care plans viewed were more of an assessment rather than a plan of how to meet the need of the resident. The registered person should ensure that all plans provide a clear plan of how residents’ needs are to be met. This requirement will be carried forward. There was evidence that residents were involved in the creation of plans and that they were being reviewed. Plans provided evidence that residents’ medical needs were being met, but some did not provide evidence that they were being regularly weighed. If residents refuse to be weighed or cannot be weighed for any reason this should be recorded on the record sheet. Residents spoken with said that they felt staff were kind and caring and looked Autumn Grange Care Home DS0000002190.V265956.R01.S.doc Version 5.0 Page 11 after them. Residents also said that staff tried to get a doctor out to see them but one resident said that it did take a long time for the doctor to visit. This appeared to be linked to the surgery and not as a result of the staff not contacting the doctor. Care plans identified risks and what action needed to be taken to minimise the risk. A flow chart looked at the need for bed rails and what alternatives have been looked at, which is good practice. Medication records were viewed, it was apparent that due to the manager being on emergency leave that prescriptions had not been collected from some of the surgeries. This meant that when the deputy realised it was too late to get the pharmacist to make them up into blister packs for ease of administration. This had meant for this month all medications were in their original bottles. The registered person must ensure there is a system in place that minimises the risk of this happening again. Some of the bottles viewed had been taken out of the box they were prescribed in and the prescription details linking them with the person they were prescribed to, were missing. Some of the records on the Medication Administration Record Sheets were hand written, where this is necessary they should be signed and countersigned to minimise risk of error. Medication needed to be stored in the fridge was appropriately stored but the monitoring of the fridge temperatures was unavailable for inspection as was the drug returns book. The registered person must ensure that this information is available at all times. In discussion with the deputy manager it became apparent that a resident who was on a particular medication was being told it was an iron tablet not a water tablet. Apparently this was done as the resident would not take it and the practice appeared to have started in hospital. On no account should residents be given medication covertly. If the resident continuously refuses medication this should be noted and brought to the attention of the prescribing GP to arrange an alternative. A number of the care plans viewed had some information regarding their wishes should their health deteriorate and they need more help. The home has a policy and procedure regarding the care and comfort of the dead and dying. A requirement was set at the last inspection regarding this and has yet to be fully met. This requirement will be carried forward. Autumn Grange Care Home DS0000002190.V265956.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: These standards were all fully inspected at the inspection on 16th June 2005. Autumn Grange Care Home DS0000002190.V265956.R01.S.doc Version 5.0 Page 13 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 and 18 Policies and procedures are in place to ensure residents complaints are listened to an acted upon. Residents are protected from abuse. EVIDENCE: The home has received no complaints since the last inspection. The Commission received one anonymous complaint, which the manager and registered person responded to following the homes own complaints procedure. The outcome of this was not discussed at the inspection, as the manager was not available. Residents spoken with said that if they had a problem they would tell the manager and would feel confident that she would deal with it. Staff spoken with understood what constituted abuse and what they needed to do to protect residents. Evidence was seen that staff were undergoing abuse awareness training. Residents spoken with said they felt safe in the home. The local Nottinghamshire Committee for the Protection of Vulnerable Adults (NCPVA) Policy and Procedures is available, which ensures that residents are protected from abuse. Autumn Grange Care Home DS0000002190.V265956.R01.S.doc Version 5.0 Page 14 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, 24, 25 and 26 The home is not well maintained and places residents and staff at potential risk. EVIDENCE: This part of the inspection took place with Steve Matthews Environmental Health Officer for Nottingham City Council. During a partial tour of the building it was noted: • The passageway leading from the reception area to unit one, a double socket was loose and hanging from its fixture, creating a hazard. This must be made safe. • The Perspex panelling along the wall was loose and attempts to fix it the wall by using panel pins had created a risk to residents as the panel pins were sticking out and the edges of the panel were very sharp and also sticking out. The panelling throughout the home must be made safe and free from sharp edges. • Throughout the building a number of lights were noted not to have covers on them. This creates an atmosphere that is not homely. Autumn Grange Care Home DS0000002190.V265956.R01.S.doc Version 5.0 Page 15 • • • • • • • In the corridor identified the light was not working and this created a possible trip hazard where the floor surface changed height. The threshold carpet by a fire exit should be risk assessed for its potential to be a trip hazard. In a number of ensuite it was noted that the extractor fans did not work. In the recently refurbished shower room the cover was missing from the light and the extractor fan. The cellar where continence aids are stored only has a light at the top of the stairs but not in the body of the cellar. As a result continence aids have been stored at the foot of the steps creating a trip hazard. The light must be replaced in the cellar. It was noted in a number of areas that the Altro flooring was lifting. The registered person must ensure that this is fixed to minimise the risk of residents and staff tripping. Outside of an identified bedroom there was a large amount of debris from previous building work. This should be removed or more suitable storage found. Several bedrooms were viewed during the tour of the building, one bedroom viewed, which was a shared room did not have screening at the time of the inspection and the pole where the curtain should hang was extremely loose and flimsy in its construction. This poses a potential risk to residents should they pull on the curtain. None of the residents spoken with said they had a key to lock their bedrooms. Although some residents said they did not mind others said they would like the opportunity to lock their doors. The registered person must risk assess all residents regarding their ability to have a key to their bedroom. All bedrooms viewed had suitable beds and rooms were carpeted, bed linen was available for residents use. A requirement was set at the inspection 0n 16th June 2005 regarding the lighting in identified bedrooms. The manager has improved the lighting in these areas; therefore ensuring residents live in suitably lit environment. This requirement is now met. All radiators and pipe work have guards on protecting residents from the risk of burns. On the day of the inspection the home was clean, cleaning staff were in evidence throughout the day. It was noted however a number of toilets around the building were badly stained and need attention. The laundry was suitable with hand washing facilities close by; the floor is impermeable and can be easily cleaned. There are sluicing facilities and foul washing is washed at appropriate temperatures ensuring residents and staff are not placed at risk of infection or toxic conditions. Autumn Grange Care Home DS0000002190.V265956.R01.S.doc Version 5.0 Page 16 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): 28, 29 and 30 Policies and procedures are in place to ensure recruitment is robust and residents are protected. Staff receive suitable induction and training to meet the needs of residents. EVIDENCE: Staff spoke with said that they were able to access a number of training courses including NVQ 2 the home is currently working towards having 50 of staff NVQ 2 trained ensuring residents are supported by trained and experienced staff. Some staff files were viewed but not all the information could be looked at as the manager was unavailable. A previous requirement was made staff having two references on file. All the files inspected had two references this requirement is now met. Evidence was seen that staff have attended a number of training courses over the last year. An immediate requirement was set at the inspection on 18th August 2005 following the outbreak of Diarrhoea to ensure that all staff receive food hygiene training. The manager provided evidence that this requirement was met within the seven days time scale set at the inspection. Staff spoke with all confirmed that there is no problem in accessing training and time is given to attend. Evidence was also seen on the day of the inspection that staff are being given refresher manual handling training. Autumn Grange Care Home DS0000002190.V265956.R01.S.doc Version 5.0 Page 17 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, 34, 37 and 38 EVIDENCE: The manager has been in post a number of years and is aware of her responsibilities as registered manager. She works in conjunction with the Commission to ensure where possible that requirements are met within timescales. The manager is in charge of only one establishment and is familiar with the conditions associated with old age. Residents spoke with were all positive in their views of the manager and felt confident in her to ensure they were well looked after. A requirement had been set at the inspection on 16th June 2005 regarding effective quality assurance, however as the manager was unavailable this requirement will be looked at more detail at that time. Policies and procedures viewed during the course of the inspection had not been reviewed for over two years and the manager must ensure that Autumn Grange Care Home DS0000002190.V265956.R01.S.doc Version 5.0 Page 18 this is done to ensure that practice within the home is in line with current good practice. The home has suitable insurance to ensure the building and business are protected. The Commission currently has no concerns regarding to the business’s financial viability. Residents’ care plans are stored appropriately as are staff files, however during the inspection the Environmental Health Officer and the Inspector wanted access to various documents regarding health and safety practice within the home. The deputy manager said she was unable to access this, as they were stored in the manager’s office, which was locked. The registered person must ensure that all relevant documents are at all times available for inspection in the care home by any person authorised by the Commission to enter and inspect the care home. There was evidence that staff were undertaking refresher moving and handling training, staff were undertaking first aid training and after the inspection on 18th August 2005 where an immediate requirement was left following the outbreak of diarrhoea ensuring that risk assessments regarding food hygiene practices in the kitchen were undertaken. The manager provided copies within the seven-day timescale set at the time. This requirement is met. The accident book was examined, the manager must ensure that these records are stored correctly, as currently all records of accidents are left in the book itself. Confidential information must be stored according to the Data Protection Act 1998. A number of areas regarding the health and safety of the building were not inspected due to the absence of the manager. The Environmental Health Officer plans to return to complete this part of the inspection. Autumn Grange Care Home DS0000002190.V265956.R01.S.doc Version 5.0 Page 19 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 X 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X 2 3 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 3 X X 2 2 Autumn Grange Care Home DS0000002190.V265956.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Timescale for action 31/01/05 2. OP9 13(2) 3. OP9 13(2) The Registered Person should ensure that each service user has a written plan as to how the service users needs in respect of his health and welfare are to be met. The identified plans should be written in more detail. (Outstanding Requirement 30/09/05) The Registered Person shall 01/12/05 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Appropriate arrangements must be made to ensure that prescriptions are picked up in time to take to the pharmacist. 01/12/05 The Registered Person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The Registered Person must ensure that medicine record sheets are appropriately signed and witnessed when hand written. DS0000002190.V265956.R01.S.doc Version 5.0 Autumn Grange Care Home Page 21 4. OP9 13(2) 5. OP9 13(2) 6. OP9 13(2) 7. OP11 12 8. OP19 13(4) 23(2)(b) (o) The Registered Person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Staff must not give medication to residents covertly. The Registered Person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The fridge temperature must be recorded to ensure it is operating within safe margins. The Registered Person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. It must be clear on all medication who the medication is intended for. If liquid medication is prescribed, prescription details must not be separated from the bottle. The Registered Person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users, to make proper provision for the care and where appropriate, treatment, education and supervision of service users. The manager must ensure that plans of care provide information regarding the care and comfort of service users as and when they deteriorate. (Outstanding Requirement 30/09/05) The Registered Person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to DS0000002190.V265956.R01.S.doc 18/11/05 31/12/05 18/11/05 31/01/05 31/12/05 Autumn Grange Care Home Version 5.0 Page 22 9. OP24 12(4) 16(2)(c) 10. OP33 24 11. OP37 17(3)(b) 12. OP38 17(1) their safety. The registered person must ensure that all identified hazards created by poor maintenance are corrected. The registered person shall provide in rooms occupied by service users adequate furniture, bedding and other furnishings including curtains and floor coverings and equipment suitable to the needs of the service users and screens where necessary. The registered person shall maintain the quality assurance system that reviews and improves the quality of care at the care home, and supply the Commission with a reporting respect of any review and make a copy of the report available to service users. (Outstanding Requirement 31/07/05 The registered person must ensure that all relevant documents are at all times available for inspection in the care home by any person authorised by the Commission to enter and inspect the care home. The Registered Person shall ensure that accident records are kept securely in the care home in accordance with the Data Protection Act 1998. 31/12/05 31/12/05 31/12/05 31/12/05 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 Autumn Grange Care Home DS0000002190.V265956.R01.S.doc Version 5.0 Page 23 1 OP33 The registered person should carry out regular reviews of policies and procedures in light of changing legislation and good practice advice. Autumn Grange Care Home DS0000002190.V265956.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Autumn Grange Care Home DS0000002190.V265956.R01.S.doc Version 5.0 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!