Inspection on 09/08/07 for Bedale Grange Nursing Home

This inspection was carried out on 9th August 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bedale Grange Nursing Home 29/07/08

Bedale Grange Nursing Home 29/08/06

Bedale Grange Nursing Home 15/12/05

Bedale Grange Nursing Home 13/09/05

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Bedale Grange Nursing Home 28 Firby Road Bedale North Yorkshire DL8 1AS Lead Inspector Jo Bell Unannounced Inspection 9th August 2007 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 Bedale Grange Nursing Home DS0000064737.V343740.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. Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bedale Grange Nursing Home Address 28 Firby Road Bedale North Yorkshire DL8 1AS 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) 01677 422980 01677 427535 bedalegrange@yahoo.co.uk Bedale Grange (TFP) Ltd Mrs Julie Atkins Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th July 2006 Brief Description of the Service: Bedale Grange is a care home registered to provide Nursing and Social care for up to 21 residents. It is located just west of the small market town of Bedale and was first registered as a Nursing home in September 1985. The home is a large detached pebble-dashed building with three floors including ground and single storey extensions have been added. There is an electric chair lift from the ground to the first floor and people are accommodated on the ground and first floors only. The front elevation facing south overlooks a large garden area that has a pergola with lawn, mature trees and shrubbery extending beyond. The fees per week range from £400-£600. This information was correct at the time of the visit. The statement of purpose details services and facilities and a copy of the inspection report from last year is available for all potential people wishing to use the service. Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key inspection of the service took place on Thursday 9th August 2007. Prior to the site visit an annual quality assurance assessment was completed and surveys were sent out to thirteen people using the service (this was everyone who was resident at the time of surveying). Their relatives, and a range of healthcare professionals were also sent surveys. Three surveys were returned from people using the service, six relatives surveys and four healthcare professional surveys were returned. The site visit lasted for 6.5 hours, during this time one inspector spent time with three people discussing in detail their care, medication, environment, staffing issues and any concerns they had. Three relatives discussed their views of the home. Five other people were spoken with throughout the day during observations of care practices in the lounge area. The manager was available to assist during the visit and discussions took place with staff members including a registered nurse, care staff and catering staff. Documentation relating to health and safety, training, recruitment and complaints were examined and the progress of the service since the last visit 12 months ago was discussed. Overall people enjoy living in the home and feel the environment is suitable and the care is satisfactory. What the service does well: People are cared for by staff who understand their needs and treat them as part of an extended family. One person said ‘the staff are great and really know what they are doing’. Another person stated “ every member of staff are unfailingly kind and patient”. One relative surveys stated “The home provides a decent, clean and pleasant environment, with pleasant staff and good food and accommodation”. The quality of food and drink provided is good, people enjoy mealtimes and comments including ‘the food is lovely here’ and ‘lots of the food is homemade’ were made. Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 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 Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (standard 6 is not applicable) People who use the service experience good quality outcomes in this area. Needs are assessed in a detailed manner prior to admission. We have made this judgement using available evidence including a visit to the service. EVIDENCE: Pre-admission assessments are carried out by the manager of the home, where a person is care managed an assessment from the care manager is also obtained. The manager has a good understanding of the client group who can be cared for in this nursing home. Whilst there are some people with dementia their nursing needs outweigh their mental health needs and staff feel their needs are being met on a daily basis. One person using the service and their relatives confirmed that the manager had completed an assessment. Questions regarding health and personal care and social history are asked and the answers are recorded in the assessment documentation. Evidence of this was examined and this confirmed that this takes place in a detailed manner. The home have ‘rapid response’ beds which are used for emergencies, when this is needed an assessment is obtained prior to the person entering the home. No intermediate care is offered. Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 People who use the service experience adequate quality outcomes in this area. Health and personal care needs are not consistently met, and aspects of medication need improving. We have made this judgement using available evidence including a visit to the service. EVIDENCE: Generally people were well cared for with care plans that described people’s needs and the interventions needed to meet these. One person stated “the matron and staff of this home are wonderful”. Three care plans were inspected in detail these contained residents profile, past medical history, social and religious needs and risk assessments relating to nutrition, prevention of pressure sores, falls and moving and handling. There were some gaps in the care plans though reviews and evaluations had taken place. Currently no care plan audits take place. This would identify any omissions and whether needs were being recorded and met. People spoken to confirmed that they receive visits from the doctor or dentist as needed and one member of staff was organising a chiropodist to come and visit. The registered nurses are up to date with wound care and are in the process of completing a dementia course. One person said ‘the staff are really kind and caring’, a Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 Page 10 relative said ‘I have no concerns at all, the staff are good and know how to care for people’. It was evident that people who use bed rails did not have risk assessments in place, on one occasion this was not discussed in the care plan and it was unclear as to the rationale for using these. Three rooms were checked where bed rails were in use, currently folded duvets instead of the correct bumpers are being used. This needs to be addressed to ensure people’s safety. One person’s care plan had a completed wound assessment which was detailed and discussed the frequency of dressing changes, however this was not adhered to. Observations showed this person having to sit with leaking bandages on her legs, the manager stated these should have been changed yesterday but staff did not have time. At the end of the site visit the dressings still had not been changed, this was unpleasant and undignified for the person concerned and also not very pleasant for other people sat next to her. This person’s needs were not being met. The medication system was inspected, currently people are at risk because there are inconsistent practices regarding the administration and recording of prescribed medication. Three charts were inspected all three had errors. For example: - blanks were identified regarding administration of warfarin, digoxin, trazodone, madopar, furosemide. As no stock balances were taken it was unclear if this medication had been given and not signed for or just not given. This has an impact of people’s health and could cause people to be unwell if their medication is not given correctly. -People had been given out of date eye drops, there was no date as to when they were first opened and these were not always signed for. -One person who should have had her blood glucose levels recorded daily had omissions of her chart, sometimes it was completed twice a day or once a day or not at all. This needs to be consistent. -Staff had not consistently being using the coding system, it was unclear as to whether staff had asked a person whether they needed pain relief or constipation medication or whether it had been forgotten. -No medication audits are taking place, this would identify the issues arising and action could be taken to prevent or reduce them. Privacy and dignity in the home was discussed, currently there are no signs on bathroom/shower/toilet doors, this would be beneficial. In one shower room whilst there is a low privacy screen there is no curtain to prevent staff walking into this room when someone is having a shower. On one occasion a member of staff spoke sharply to a person and then complained to another member of staff about the person’s behaviour. This is not acceptable and the manager was made aware of this. Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 People who use the service experience adequate quality outcomes in this area. People need to be offered more choice and autonomy at mealtimes, and more activities should be made available. We have made this judgement using available evidence including a visit to the service. EVIDENCE: People do have access to a limited amount of activities. Some comments made in the surveys stated that more activities and stimulation are needed. For example at the site visit people were watching television, reading newspapers or spending time in the garden, there is a resident dog which offers companionship and the goldfish are relaxing to watch. The home does not have a designated dining or activities room and therefore people are sat in one place for long periods of time. Visitors are encouraged and they are able to see people in their own bedrooms if wished. The visitors book confirmed people can visit at any time during the day. The home does not have an activities organiser and staff can only offer activities on a limited basis when they have time. People are offered choice regarding their daily activities, one person said ‘I can get up and go to bed when I want to’. Two relatives confirmed that staff are happy to fit in with whatever their relative chooses to do. Church services take place on a monthly basis, and people are encouraged to take people to their local church if able. Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 Page 12 Breakfast and the lunchtime meal were observed. The staff ask people on a morning what they would like for lunch and tea. A cooked breakfast is always available (this was observed), and an alternative to the one main meal is offered at lunchtime. Food is home made with fresh vegetables and cakes and biscuits along with fruit are always available. The portion sizes are suitable and staff were observed assisting people in a pleasant sand dignified manner. Do to the lack of dining facilities people had to sit in the same place with a small table pulled up to their chair to eat their meals from a tray. This made it difficult to socialise as people were sat in a straight line and not facing other people. The cook was knowledgeable about how to fortify foods and how to make soft and pureed diets look presentable. Food was stored correctly in the kitchen and areas were clean and well maintained. Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. People are aware of how to complain and the risk of harm is minimised through good adult protection procedures. We have made this judgement using available evidence including a visit to the service. EVIDENCE: The home has a complaints procedure in place. All people spoken to including their relatives and staff all confirmed that they know how to raise concerns and they felt that the manager would deal with these appropriately. Surveys returned had positive comments regarding complaints. Meetings for people using the service take place and three people who were discussing their care during the day all agreed they had no complaints but they are aware of the procedure to follow. One complaint had been made and this had been dealt with effectively. The risk of harm to people is reduced through an effective adult protection policy and procedure. Staff receive training in abuse awareness and two care staff discussed the action they would take if they observed abuse taking place. Staff were aware of the different types of abuse and the procedure they would follow (including whistle blowing) The manager knows how to refer an issue to social services and how to make a referral to the protection of vulnerable adults team (POVA). All staff have a police and POVA check prior to starting work in the home. People looked safe, and no-one raised any concerns regarding the staffs attitude or manner. Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience adequate quality outcomes in this area. Generally people live in a clean and fresh smelling environment. Though aspects of infection control could be improved on. We have made this judgement using available evidence including a visit to the service. EVIDENCE: The home is located in a pleasant area of Bedale with a short walk to the garden area. There is a plan in place to obtain a canopy for use outside the entrance area which will shade people if they wish to sit outside. The home is kept safe and well maintained. As previously mentioned there is no designated dining area and one communal lounge is available for up to twenty one people. Generally the home smelt clean and fresh. Three people confirmed their rooms smell pleasant and that there are enough domestic staff to ensure the home is cleaned effectively. In one room there was a very strong smell of urine which needs to be removed, this will make it more pleasant for the person spending time in the room. The laundry area was examined, there is currently no lock on this door. This would be beneficial as there are chemicals on display in this area. The home have one washing machine and one tumble drier. This is Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 Page 15 sufficient. People had clean clothes on which were well ironed. Staff do need to undertake infection control training, in discussions with staff they could not confirm when this training had taken place and the records were not completed. Staff were observed washing their hands, and wearing gloves and protective aprons, though there was a risk of cross contamination by staff entering and exiting the kitchen without protective clothing. The issue of people having lockable spaces was discussed, the manager will consult with everyone living in the home to determine whether they wish to have a lock either on their door or a lockable space in their room. The manager confirmed that the call bell system is due to be updated as currently the call bells upstairs can be cancelled downstairs without the member of staff having to go to where the bell has been pressed. This may mean that a person is waiting for assistance and a staff member has not seen them. Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 People who use the service experience good quality outcomes in this area. Care needs are currently met with sufficient staff, who are competent and safely recruited. We have made this judgement using available evidence including a visit to the service. EVIDENCE: People are cared for by sufficient staff who are competent and able to care for older people with nursing needs. The duty rota confirmed that staffing levels were satisfactory. Although almost half of the people living in the home need to use moving and handling equipment to transfer them safely. Two staff are often needed to help with this manoeuvre. During the morning there is one registered nurse with three care staff, on an afternoon this is reduced to two care staff which can make it difficult to spend quality time with people. However people spoken to felt their needs were generally met. Three relatives confirmed that staff are competent and appropriately trained. Staff have a good rapport with people and clearly know them well. Many staff have completed an NVQ level 2 or 3. Two care staff confirmed this. Staff have to complete induction training which is equivalent to Skills for Care. This covers health and safety and care practices needed for staff to carry out their role. This may take up to six weeks to complete and staff are assigned a mentor who supervises them during this time. Recruitment procedures were inspected, people are only employed once they have a clear police check and a protection of vulnerable adults check. This helps to protect people against harm who are using the service. Three files Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 Page 17 were checked which contained detailed information on each member of staff. Registered nurses identification numbers are checked through the Nurses and Midwifery website. Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 Page 18 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 who use the service experience adequate quality outcomes in this area. People enjoy living in the home though currently there are inadequate fire safety systems, insufficient quality assurance systems and unclear staff training information available. We have made this judgement using available evidence including a visit to the service. EVIDENCE: The manager is a general nurse who is registered with the CSCI. She has many years experience in working with older people and has been the manager for seven years. She has one supernumerary day per week and whilst this would be adequate if all the documentation systems were already in place this is not the case. The quality assurance system is weak, surveys are sent out annually but currently no audits take place. For example care plan, medication, accidents or pressure sore audits are not in place. This would help identify how the home is Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 Page 19 progressing and which areas need to be improved on, this would have a positive effect on people using the service. This was highlighted twelve months ago and little progress has been made, errors are occurring in some of these areas and this is going undetected. Staff have meetings but these are not documented. Informal discussions take place with people but there is no written evidence of this. However, the manager is not familiar with this process as this has never been explained to her fully. She needs to feel supported by senior managers and have a greater understanding of her role in order to carry it out effectively. Whilst staff feel they can come to the manager with any concerns and they will be sorted out, the manager needs to be more assertive with staff and take action when areas are identified which staff need to improve on. For example currently training records are not up to date, the manager does not have a complete understanding of which training has taken place and when the last training was completed. This includes fire safety, infection control, and food hygiene. Moving and handling training is currently being completed. One record suggested that one staff member has not completed infection control training for ten years. The training matrix is not up to date and the training files whilst individual have different information in which is not current. The home does not deal with individual finances, this was confirmed by the manager and when speaking to people they stated they are invoiced for any extra charges i.e. hairdresser or chiropodist. Health and safety in the home was discussed and aspects of the environment were examined. An electrical wiring certificate was examined for 2004, emergency lighting is in place and water temperatures have been checked and were found to be within expected parameters. Portable appliance testing takes place and hoists are checked every six months. It would be beneficial to have an electric hoist for downstairs as currently staff are having to cope with a manual hoist. The home have a completed fire risk assessment and fire alarm testing takes place on a regular basis, though this has not been documented since June 2007. It was evident that a number of rooms were propped open using door wedges, the door would not automatically close in the event of the fire and it could not be contained if a fire arose in one of these rooms. The manager was alerted to this who was aware of this but no action had been taken to rectify this. Approximately six people had chosen to have their bedroom doors open. A letter of serious concern was issued as no risk assessments were in place and no other solution had been found to adhere to fire safety and take into account individuals preference for keeping their room door open. Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 Page 20 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 2 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 1 x 3 x x 1 Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 Page 21 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 OP8 Regulation 13(4) Requirement People must have risk assessments in place for the use of bed rails, this ensures they are used appropriately. The correct bumpers must be used to protect people from hurting themselves. Medication prescribed must be administered and signed for in line with the home’s policy. i.e. warfarin,digoxin,furosemide, trazodone & senna. Eye drops must have a date of opening on them to ensure they are safe to use. A clear audit trail of medication must be in place. The strong smell of urine in one room identified must be removed. This will make the room more pleasant to spend time in. Timescale for action 09/09/07 2. OP9 13(2) 23/09/07 3. OP26 16(2) 12/08/07 Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 Page 22 4. OP33 24(1)(a) A quality assurance system must be introduced. This will ensure that peoples views and opinions are heard and acted upon and care practices are routinely monitored. (Two Previous Timescales of 01/04/06 & 01/04/07 not met) 09/09/07 5. OP38 17 A plan of mandatory training 09/09/07 which has taken place during the past 12 months must be forwarded to the CSCI within one month. This will help to identify if people are cared for by staff with current knowledge of care practices. Fire alarm testing must be documented at each test. Fire safety must be adhered to ensure people are kept safe. Doors must not be propped open by unauthorised means. Risk assessments must be completed for those people wising to keep their room doors open, and an alternative solution must be found. Immediate requirement issued. 09/08/07 13/08/07 6. 7. OP38 OP38 23(3) 23(3) Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 Page 23 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. 2. 3. 4. Refer to Standard OP10 OP12 OP15 OP33 Good Practice Recommendations A privacy screen should be fitted to the shower room. More activities should be offered on a daily basis. People would benefit from having a designated dining area. The quality monitoring system should include care plan and medication audits, along with accident and pressure sore monitoring. A power assisted hoist for use downstairs would be beneficial to help the staff move people more effectively. 5. OP38 Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Bedale Grange Nursing Home DS0000064737.V343740.R01.S.doc Version 5.2 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. 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