Inspection on 20/05/08 for Broadoak Grange

This inspection was carried out on 20th May 2008.

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

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

Other inspections for this house

Broadoak Grange 05/07/07

Broadoak Grange 11/07/06

Broadoak Grange 18/05/05

Broadoak Grange 03/02/05

Broadoak Grange 04/05/04

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Broadoak Grange Sandy Lane Melton Mowbray Leicestershire LE13 0AN Lead Inspector Thea Richards Unannounced Inspection 20th May 2008 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 Broadoak Grange DS0000001648.V364871.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. Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broadoak Grange Address Sandy Lane Melton Mowbray Leicestershire LE13 0AN 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) 01664 562008 01664 562008 Mr John Nunn Mrs Barbara Elsie Nunn Mrs Eulie Gwendolyn Nicol Care Home 33 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (33), of places Physical disability over 65 years of age (10) Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No person falling within Category PD(E) may be admitted to the Home when there are 10 persons of Category PD(E) already accommodated. Service User Numbers No person to be admitted to the home in categories MD(E) or DE(E) when 10 persons in total of these categories/combined categories are already accommodated within the home. 5th July 2007 Date of last inspection Brief Description of the Service: Broadoak Grange Residential Home is a care home providing personal care and accommodation for 33 older people with a physical frailty and/or mental health needs. The home is owned by the Registered Providers Mr and Mrs Nunn and is part of fifteen homes owned by the Broadoak Group of Care Homes. There is currently not a manager in the home, but one is expected to join the company shortly. The home is situated on the outskirts of Melton Mowbray and can be reached by private and public transport. There are local shops close to the home. The accommodation is a purpose built, two- storey home with two lounges and two dining rooms on the ground floor. There are bedrooms on both floors and the first floor can be reached by stairs or by a passenger lift. There are single and shared bedrooms, all of which have en-suite facilities. Outside, there is a well - maintained garden, with seating and a greenhouse, which is easily reached for the residents to use in the better weather. The current registration certificate from the Commission for Social Care Inspection is available in the reception area with an up to date insurance certificate. The latest report from the Commission for Social Care Inspection is available in the managers’ office. The home’s brochure provides information about the service to prospective and current residents and includes the terms and conditions of the stay. Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 5 The home can be contacted by telephone, or fax. The current level of fees range from £343.00 to £460.00pw. There are extra charges for hairdressing, chiropody, newspapers and personal items. Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 1 Star. This means that the people who use this service experience adequate quality outcomes. This was a key inspection of a care home for older people, which ended with an unannounced visit to the service. Before the visit we (throughout the report the use of ‘we’ indicates the Commission for Social Care Inspection), spent four hours reviewing information received by the Commission for Social Care Inspection (CSCI) since the last inspection on 5th July 2007. We were unable to send surveys to residents, families or staff on this occasion. The visit took place on the 20th May 2008 and lasted five hours. During the visit we checked all the ‘key’ standards as identified in the National Minimum Standards. This was achieved through a method called ‘case tracking’. Case tracking means that we looked at the care provided to three of the residents. To achieve this, the residents were spoken with. We spoke with the staff supporting their care and looked at the records relating to their health and welfare. With their permission the residents’ bedrooms were looked at. We also checked how the home was run and organised. This included looking at staff records, training and how the staff are organised. We looked at health and safety records, menus, minutes of meetings and the quality audit. The policy for handling complaints and how the home dealt with them were looked at. We looked at how prospective residents and their families are given information about the services the home can offer and whether they are suitable for them. During the visit we spoke with the registered manager, the staff and the residents and their families. We also spoke with a National Vocational Award Assessor and a district nurse who were visiting the home. What the service does well: The staff give committed and dedicated care to the residents. ‘I am happy in the home and the staff look after me well’ Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 7 The home provides a clean and welcoming place to live in. The home gives the residents good home cooked food and provides choices in what they have to eat. The manager and the staff welcome visitors into the home and communicate well with them. The home has a good recruitment practice, with all the required documentation in them. This makes sure that, as far as possible, the residents are safe. What has improved since the last inspection? What they could do better: A thorough Statement of Purpose must be produced to give prospective residents and their families a clear idea of the care and the facilities that the home can provide. There should be provision made for the document to be produced in other formats such as large print and other languages. There should be a formal pre-admission assessment document produced and completed for every resident, including those who are local authority funded. This will give the manager a clear idea of the resident’s needs and how the home can meet them. Each prospective resident should have a visit, made by a suitably trained member of staff, to make sure that the home can meet their needs. Menus could be reviewed to make sure that there is more variety of meals for the residents. Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 8 The accident book should have separate pages for each accident that happens, to make sure that confidentiality is kept. The fire alarm testing must be kept up to date. The alarm points should be tested in turn to make sure that they are all working correctly. The homes’ application for employment should be altered to allow enough space for a proper record of applicants’ previous employment to be recorded. The provider should inform the Commission for Social Care Inspection (CSCI) that the previous registered manager is no longer in post. The completed Annual Quality Assurance Audit for the CSCI should be returned to them. The staff should be given the opportunity of regular formal supervision to give them the time with their ‘line manager’ to discuss work and training issues. 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. Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5. 6 is not applicable in this home. Quality in this outcome area is poor. This judgement has been made using the available evidence. The residents’ needs are not adequately assessed and they do not have the required information needed to make a appropriate choice of home. EVIDENCE: The Statement of Purpose is displayed in the reception area, but is a single sheet of paper giving a statement of the homes aims and objectives. This should be expanded to give people the information that they need to make an informed choice about the home and could include results of quality audit. Prospective residents will then be able to read the comments from the residents and their families, which will help them in making a decision about the home. Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 11 The Statement of Purpose and Service Users’ Guide should provide all of the required information about the services offered and the Terms and Conditions that apply, making sure that residents can get the most suitable care. There was no evidence that a pre admission assessment had been made by the home in any of the files looked at. Those residents who had been placed by the local authority had assessments in place. Good practice would mean that somebody from the home makes a visit to all of the prospective residents and completes their own assessment. The person in charge at the time of the visit told us that there was no pre – admission assessment form in place and that no visits were made. A family spoken with whose relative had been admitted recently had not had a visit or an assessment made. They told us that they had not received any written information about the home, but had made a visit. They were very happy with the care that their relative was having. These practices would make sure that that the staff in the home have the right information before the resident moves in and that they can meet their needs. It also makes sure that the resident meets someone from the home who they can recognise, which makes the move into care easier to manage for them. The home does not offer intermediate care facilities. The current registration certificate from the Commission for Social Care Inspection (CSCI) and up to date details of insurance cover are displayed in the entrance of the home. Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome group is good. This judgement is made using the available evidence including a visit to the service. The staff meet the care needs of the residents as identified in the care plans with privacy, dignity and respect. EVIDENCE: The care plans for the ‘case tracked’ residents were found to contain good individual evidence of care, which reflects the care being given to the residents. There were risk assessments in place where risks to the residents have been identified. There are records of visits by professional staff, such as Doctors, district nurses and chiropodist. This shows that the residents are having the right medical care given to them. Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 13 The residents, the families spoken with all said that they were happy with the care being given and that they had medical attention whenever they needed it. ‘ I am happy in the home and the staff look after me well’ There are records of the residents’ weight, which makes sure that they are not losing or gaining large amounts of weight. The daily record of care is up to date which makes sure that the residents receive the right care and the staff know what has happened to them during the day or night. Staff spoken with were aware of the residents care needs. There is documented evidence of the review of the care plans involving the residents’ families. The residents and the families spoken with on the day of the visit confirmed that they had been involved. We spoke with a district nurse who said that the staff were very aware of the residents needs and asked her to see them when needed. We spoke with a National Vocational Award assessor who told us that the staff were well trained in the home and that she always found the residents to be well looked after. When the staff were giving care and speaking with the residents they were seen to be doing so with dignity and respect. The residents spoken with were happy with the way staff treated them and said that they were very kind. Medication records were correct and the staff spoken with were fully aware of the process for the ordering, receipt, administration, storage and disposal of the medicines. The staff were seen to be giving out the medicines correctly and making sure that the residents had taken them. The staff who give the medicines have all had training to do so, this was confirmed by the staff spoken with, the manager and by the records seen. The controlled (dangerous) medicines were checked and they and the records were found to be correct. The manager audits the medicines regularly and documents the result. The room where the medicines are stored in locked cupboards was found to be unlocked. As there were medicines waiting to be returned at the end of the month it should have been locked so that any confused residents could not reach them. The person in charge immediately had the room locked. Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 14 There is a policy in place for self -medicating, but there are no residents selfmedicating at present. Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome group is good. This judgement is made using available evidence including a visit to the service. Residents have their social, spiritual and nutritional needs met. EVIDENCE: The staff were seen to be spending individual time with the residents. The T.V was on in both of the lounges, which the residents were enjoying. The residents spoken with were happy with the level of activities and said that they had enough to do. The families spoken with felt that there were enough activities for the residents to do. There was evidence in the daily records and in the care plans about the activity that the residents take part in. All the families spoken with said that they were made very welcome in the home, which we saw whilst we were there. Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 16 The residents spoken with said that the food was good and that they had a choice of what they had. The menus were varied and were discussed with the residents individually. We spent time talking with the residents at lunch- time. The meal looked plentiful and well presented and the residents were enjoying it. The menus looked at could be reviewed to provide more variety, as there were a lot of meals, which contained chicken. The religious needs of the residents are met individually as requested with the residents either going out to services or the clergy visiting the home. A hairdresser visits the home every week, which the residents enjoy. Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17,18. Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. There are systems in place to support and protect residents and staff are aware of the processes. EVIDENCE: There is a complaints policy in place which gives the details of how to complain and who to complain to if they needed to. This can be made available in a large print , which makes sure that as many people as possible can read it. The documentation for recording complaints was not available for us to look at on the day of the visit. The residents and the families spoken with were aware of the policy and were aware of how to complain and who to complain to. They were happy that their concerns would be listened to and acted on. The staff spoken with were aware of how to handle any complaints. The residents and the families spoken with and through the surveys were aware of the policy and were aware of how to complain and who to complain to. They were happy that their concerns would be listened to and acted on. The staff spoken with were aware of how to handle any complaints. Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 18 Several complaints had been received by Social services since the last key inspection. Regulations were found to have been met, following a thorough investigation by all agencies. Meetings with all agencies felt the complaints were mainly found to have been malicious. The staff spoken with were aware of Safeguarding and whistle blowing and said that they had had training in these areas. They would report it to the senior carers or the management and were aware of who to go to if there was no response. The records seen confirmed this. All staff have either got an NVQ at level 2 or have started the award, during which they receive training in safeguarding. They were confident that the management would handle any issues correctly. The accident book had entries of accidents on both sides of the forms that are provided. This could give a lack of confidentiality for the residents. There was information displayed in the home letting people know where they could get an advocacy service if they needed it. These practices make sure that the residents are safe from any abuse and that any concerns are handled correctly. Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 24, 26. Quality in this outcome group is good This judgement has been made using available evidence including a visit to the service. The residents are protected by the policies and procedures in the home to provide a safe environment. EVIDENCE: Broadoak Grange is a purpose built home on two floors with two lounges and dining rooms on the ground floor. There are bedrooms on both floors and the stairs or the passenger lift reach the first floor. The home was clean and welcoming on our arrival. The two lounges and dining rooms were clean, but the decoration could be updated. Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 20 Some of the chairs were looking worn and torn in places. The provider was in the process of replacing chairs and some had arrived and were seen stored in an upstairs room. The bedrooms seen had been personalised. Some of the furniture and decoration is looking old and worn and the provider told us that he was about to renew the furniture. The residents spoken with were happy with their rooms and said that they were able to bring their own things in with them. The kitchen was clean and well kept. The bathrooms were clear of any items that could cause a hazard for the residents. The garden is pleasant and has a patio area that is accessible for the residents. The residents and the families spoken with were happy with the cleanliness of the home. There are dedicated cleaning staffing the home undertaking the cleaning who have had training in health and safety. The cleaning products are stored in a locked cupboard. There are separate staff employed who do the cooking. The staff spoken with, the records seen and witnessed on the visit confirmed that this was the case. Hot water temperatures have been checked and documented as correct. Fire alarm testing was not up to date although the fire drills were. When tested, fire alarms are not being tested at different points, which would make sure that they are all working. Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome group is good. This judgement is made using the available evidence including a visit to the service. The residents’ needs are met and the recruitment policy and the training protect their safety. EVIDENCE: The duty rota reflected the number of staff on duty on the day of the visit and all the shifts covered by the four weeks seen. The residents, staff and families spoken with felt that there were enough numbers of staff on duty to look after their needs. We looked at three staff files and the required information was complete in all of them. This included evidence of identification, adequately completed application forms, two written references, a Criminal Records Bureau (CRB) check and a Protection of Vulnerable Adults check. The application form did not have enough space on it to give details of previous employment. This is necessary to make sure that prospective staff have the right experience and that any reasons for gaps in employment can be explained. Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 22 The management makes sure that all the required documentation is in place before an employee starts work. This was confirmed by the staff spoken with who told us that they could not start until they had all the paperwork in place. There was evidence of staff training including induction and the staff spoken with confirmed that they had received recent training in moving and handling. Updates for first aid and medicine training have been arranged and this was confirmed by the staff and by the records in place. The residents and the families spoken with felt that the staff were well trained to do their job. All of the staff either hold a National Vocational Qualification (NVQ) at least at level 2 or are in the process of completing it. The National Vocational Qualification is a qualification for care staff to make sure that they receive training in the needs of the resident group whom they are caring for. Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38. Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. The lack of a suitably qualified manager could put the residents at risk. EVIDENCE: There is currently no manager in post although we were told that a new one would be starting on the 27th May 2008. The Commission for Social care Inspection has not been formally told that the previous registered manager is no longer in post. The provider is making regular visits to the home to make sure that it is running satisfactorily. Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 24 There was a senior carer from an agency in charge of the home on the day of the visit. The assistant manager came on duty later in the day. They were being supported by the provider and by a manager from another home. The residents are seen regularly on an individual basis as are the families and discussions are held on how the home is meeting their needs. There is an annual quality questionnaire sent to the residents and their families, the residents, their families and the questionnaires that we saw on the visit confirmed this. We received positive comments from the residents and the families amongst which were that there was good communication with the home and that the staff were very supportive of them and their relative. Most of the health and safety records were found to be up to date. The fire alarm testing was not up to date and it was found that when tested not all the points were being checked in turn. The residents’ accounts were seen and all in order with two signatures on entries and receipts obtained for purchases. The annual quality assurance audit asked for by the Commission for Social Care Inspection had not been retuned at the time of the visit. This gives us information about the home, the residents and the staff and the home are legally required to return it to us. There was evidence in the records and from staff spoken with that there is some staff supervision taking place, but that it is not at the required frequency. Formal supervision of the staff gives them and their ‘line manager’ the opportunity to discuss work and training issues and needs. There are regular staff meetings held, confirmed by records held and by the staff. Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 X 1 X 3 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 2 18 3 3 X X X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 2 X 2 Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 (1)(a)(b)( c) Requirement Timescale for action 30/06/08 2. OP3 14 (1) 3. OP31 38 (1)(b) That the registered provider produces a Statement of Purpose that fully describes the aims and objectives of the home, the facilities and the requirements in schedule 1 of the care standards act 2000. This was a requirement at the previous inspection on 5/07/07. The registered provider must 30/06/08 make sure that a pre –admission assessment is completed by a suitably qualified person for every resident before admission to the home. The registered provider must 06/06/08 notify the Commission for Social Care, in writing, of the death of the previous registered manager. The registered provider must return the Annual Quality Assurance Audit (AQQA)to the Commission for Social Care Inspection within the time limits required. 06/06/08 4. OP31 24(3) Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 27 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. 5. Refer to Standard OP15 OP17 OP36 OP38 OP38 Good Practice Recommendations That consideration is given to providing a greater variety of meals for the residents. That a new method of recording accidents is provided to maintain the residents confidentiality. That all the staff have formal supervision at the frequency required by the care standards act. That the fire alarms are tested at the required frequency and recorded. That all of the fire alarm points are tested in turn. Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Broadoak Grange DS0000001648.V364871.R01.S.doc Version 5.2 Page 29 - 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!