Inspection on 05/07/07 for Broadoak Grange

This inspection was carried out on 5th July 2007.

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

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

Other inspections for this house

Broadoak Grange 20/05/08

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Broadoak Grange Sandy Lane Melton Mowbray Leicestershire LE13 0AN Lead Inspector Thea Richards Key Unannounced Inspection 5th July 2007 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.V340325.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.V340325.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.V340325.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. 11th July 2006 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. Tom Nicol has been the acting manager for over a year. 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 three small 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. The home can be contacted by telephone, or fax. Broadoak Grange DS0000001648.V340325.R01.S.doc Version 5.2 Page 5 The current level of fees range from £269.00 to £379.00pw. There are extra charges for hairdressing, chiropody, newspapers and personal items. Broadoak Grange DS0000001648.V340325.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection of a care home for older people, which ended with an unannounced visit to the service. Before the visit the inspector spent four hours reviewing information received by the Commission for Social Care Inspection (CSCI) since the last inspection on the 11th July 2006. This included the Annual Quality Assurance Audit completed by the registered person. The visit took place on the 5th July 2007 and lasted six and a half hours. During the visit the inspector 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 the inspector looked at the care provided to three of the residents. To achieve this, the residents were spoken with. The inspector 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. The inspector also checked how the home was run and organised. This included looking at staff records, training and how the staff are organised. The inspector 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. The inspector 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 the inspector spoke with the manager, staff, a district nurse, the residents and their families. ‘ This is home’ Broadoak Grange DS0000001648.V340325.R01.S.doc Version 5.2 Page 7 What the service does well: 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 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 completed before 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. Broadoak Grange DS0000001648.V340325.R01.S.doc Version 5.2 Page 8 Residents and/or their families should be encouraged to sign the care-plans and be involved with the review process to make sure that they agree with the decisions. The medication process should be looked at and changed to avoid the possible risks of a resident being given the wrong medicines when a different person puts the medicines out than the one who gives it. The home should ask the chemist to give them pre-printed labels for the medicine sheets, which will avoid the risk the wrong medicine or dose being copied. Where there are high water temperatures found they should be corrected as soon as possible to avoid the risk of a resident being scalded. 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. Training in ‘Safeguarding Adults’ should be included in the staffs’ induction training, which will make sure that they are aware of the whole process of protecting the residents from abuse. 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.V340325.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.V340325.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, 2, 3. 6 is not applicable in this home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents’ needs are not always assessed before moving into the home, although they are offered the chance to visit the home. There is limited information to allow the resident to make an informed choice about the home. EVIDENCE: All of the residents who were ‘case tracked’ had been given a Statement of Purpose and terms and conditions. The Statement of Purpose and Service Users’ Guide gives very limited information that people need to know about the services offered. There is a brochure produced but this does not give enough information. Broadoak Grange should revise their statement of purpose and supply a separate service users guide. Broadoak Grange DS0000001648.V340325.R01.S.doc Version 5.2 Page 11 Providing a comprehensive Statement of Purpose & Service Users’ Guide gives good information for the residents, making sure that they they can get the most suitable care. The acting manager does not regularly visit residents before they are admitted to the home, particularly if they are local authority funded. There is not a pre admission assessment form. A visit to all prospective residents and the completion of a pre assessment should be part of the admission process for all of the residents however they are funded. This would make sure that that the manager and the staff in the home have the the right information before the resident is admitted, so that they get the best care. It makes sure that the home can meet the residents needs and that the resident meets someone from the home who they can recognise. This would make the move into care easier to manage for them. There were copies of social work assessments in the files looked at. The families spoken with confirmed that they were given the opportunity to visit the home before their relative came in. Members of the staff spoken with said that they did not always know what the resident’s needs were before they moved in. The current registration certificate from the Commission for Social Care Inspection (CSCI) was displayed in the entrance of the home. The latest report from the CSCI was available in the acting managers office. An up to date insurance certificate was displayed in the entrance hall. Broadoak Grange DS0000001648.V340325.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 area is good. This judgement has been made using available evidence including a visit to this service. The staff meet the care needs of the residents as identified in the care plans, which the residents and their families are happy with. EVIDENCE: All of the ‘case tracked records were found to contain good individual evidence of the care being given to the residents. There are records of the involvement of G.P.s, district nurses, chiropodist, optician and dentist in them, showing that thorough health care is being provided for the residents. The residents and their families spoken with, said that they could see the doctor and other health professionals when they needed to. There are records of the residents weight and of the meals that they have eaten, which makes sure that they are having an adequate diet. Broadoak Grange DS0000001648.V340325.R01.S.doc Version 5.2 Page 13 The care plans seen had not been signed by the resident or their families and they had not been involved in the review process. Signing the care plans would make sure that the resident and/or their families Knew about the care to be given and that they agreed with it. The residents and the families spoken with were happy with the care being provided and did not wish to sign the careplans. Where this is the case, the decision should be documented in the care plan. 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. The inspector saw residents generally being treated with dignity and respect when staff spoke with them and undertook their care. There was an incident seen where a resident had not had his trousers ironed, which gave him a look of being uncared for. The acting manager said that this was an isolated incident and had the trousers changed. Staff seen giving care did so in the right way, giving the residents privacy where needed, although there was little conversation with the them, other than to let them know what they were doing. Staff spoken with were aware of the care needs of the residents and the residents and the families spoken with were happy that all care needs were being met. A district nurse spoken with felt that the home had improved and that the staff knew about the residents needs and gave them the right care and attention. They were aware of when the residents needed attention from other professional people and would ask the district nurses to see them whenever necessary. There were risk assessments in place to cover all the identified risks for the residents. This makes sure that the residents and the staff are protected from any risks that have been identified, without restricting their activities. Medication records for the case tracked residents were in order. Medicines are given by the senior care staff who have had some training to give medicines. This was seen by the inspector and medicines were administered individually and the residents seen to be taking them. The staff spoken with were knowledgeable about the medicines and where to obtain information. They were also aware of the requirements for the receipt, storage and disposal of medicines. Broadoak Grange DS0000001648.V340325.R01.S.doc Version 5.2 Page 14 Some of the medicines were being hand written onto the medicine sheets, which could be unsafe, as they could be copied wrongly and the wrong dose of medicine given. The acting manager could ask the chemist to provide printed labels for all the medicines to put onto the sheets. The night time medicines are being put into pots before the senior staff go home and the night staff are giving them. This is unsafe practice as the medicines could be mixed up and the wrong medicines be given. This practice is stopping as there will in future be a senior member of staff on duty to give the medicines at night. There are no residents looking after their own medicines at the moment. Broadoak Grange DS0000001648.V340325.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 area is good. This judgement has been made using available evidence including a visit to this service. Residents have their social, spiritual and nutritional needs met. Their views are taken into consideration and acted on. EVIDENCE: There was evidence of activites being provided for the residents. Although there didn’t appear to be a very full programme of activity planned, the residents and the families spoken with were happy with those that had been arranged. During the morning there seemed to be little interaction with the residents other than to let them know what task they would be doing, such as lifting them up in the hoist. However, during the afternoon of the visit the staff were spending time with the residents with individual activities such as playing draughts or sitting talking to them. Another group of residents were watching a video. The residents have a choice of meals every day and the cook was seen to be talking to all the residents to ask which meal they would like. Broadoak Grange DS0000001648.V340325.R01.S.doc Version 5.2 Page 16 The inspector saw lunchtime in the dining room and all the residents spoken with said that they were enjoying their meal and that they always had a choice. The chef has a good understanding of the dietary needs of the residents including diabetic diets. The staff were seen to be sitting and talking with the residents whilst helping them with their meal. The manager and the staff said that visitors are made very welcome in the home and are invited to activities and may have a meal with their relative. There is regular musical entertainment which the residents enjoy. There were several visitors in the home on the day of the visit and those spoken with were positive about the communication with the manager. They felt that the level of activity arranged was suitable for the residents and that they are invited to activities and may have a meal with their relative. Visitors are made welcome in the home and the inspector saw the welcome given to them. They are spoken with regularly on a one to one basis by the manager. The manager sees each of the residents on a one to one basis every day. There are annual quality audits to get the views of the residents and their families. These practices make sure that the residents keep their contact with the community and their families and that views for improvements can be considered. Religious needs are provided for, with visiting clergy coming in to see those of the Roman Catholic faith. At the moment there are no residents who wish to take part in any other religious activity. This was confirmed by the residents spoken with. A hairdresser visits the home regularly which the residents enjoy. Broadoak Grange DS0000001648.V340325.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are some systems in place to support and protect residents and staff are mostly 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. The complaints policy was displayed on the noticeboard but there was no facility to produce it in other formats, such as large print or other languages. The complaints book was looked at and one complaint had been received since the last inspection on the 11th July 2006. This had also been sent to the Commission for Social Care Inspection (CSCI). The complaint had been about the care received by a temporary resident and had been dealt with correctly by the home, although there were no dates when it was dealt with. The residents spoken with were happy that they would speak to the manager or a member of staff if they had a problem, and that it would be dealt with. The families spoken with said that they would know how to complain if it was necessary and that if a concen had been raised it was dealt with quickly and pleasantly. Broadoak Grange DS0000001648.V340325.R01.S.doc Version 5.2 Page 18 The staff spoken with were unsure how to deal with a complaint, if it was given to them, but told the inspector that none of them had ever received a complaint to deal with. There were several letters seen, from families praising the home. All the care staff spoken with were aware of ‘safeguarding adults’, the procedure to follow and would be prepared to ‘whistle blow’ if they thought that there was a need to. Only the staff who had completed a National Vocational Award had received formal training in safeguarding adults. This training should be included in the induction training for new staff. This will make sure that the residents are safe from any abuse and that any concerns are handled correctly. Broadoak Grange DS0000001648.V340325.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, 20, 23, 24, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live in a pleasant home, which is run in their best interests. EVIDENCE: Broadoak Grange is a purpose built home on the outskirts of Melton Mowbray. There are two lounges, both of which have a television and music centres. There are three separate dining rooms, which means that the residents can have a choice of where to sit and who to sit with. The home is well maintained, clean and free from any unpleasant odours and it gives the residents a pleasant place to live in. The person who does the maintenance is shared between all the homes in the group, which means that the home can have to wait for routine maintenance tasks. Broadoak Grange DS0000001648.V340325.R01.S.doc Version 5.2 Page 20 The gardens and patio areas are very well kept and easy for the residents to get to in the better weather. The bathrooms are clean, tidy and free of any hazards. On the top floor there is a room, which is mainly used for staff training, but is accessible for the residents. On the wall in this room there was an area with bare wires. This was shown to the acting manager, who arranged to have them covered up before the end of the visit. With their permission, the case tracked residents bedrooms were looked at by the inspector. They provided good accommodation, which had been personalised with the resident’s belongings. The bedrooms were clean and well maintained. There was evidence of equipment such as hoists having been provided to help in the care and comfort of the residents. Most of the cleaning materials were kept in locked cupboards, however, in the laundry area both the machinery and the cleaning materials were accessible by the residents. This was discussed with the acting manager and he put a chain closure on the door before the end of the visit. The maintenance, hot water temperatures and fire records were checked and found to up to date. On two occasions the water temperatures were found to be slightly higher than the recommended level. This could put the residents at risk of being scalded. The acting manager arranged for the maintenance person to come and correct them. There were no other outstanding safety or maintenance issues seen on the tour of the premises. The registration certificate from the Commission for Social Care Inspection was displayed with a current certificate of insurance. The inspection reports are available in the managers’ office. Broadoak Grange DS0000001648.V340325.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 area is good. This judgement has been made using available evidence including a visit to this service. The residents’ needs are met and their safety protected by the recruitment policy and by the training that is in place. EVIDENCE: There is evidence of a good skill mix of staff to make sure that the residents have the right care. The duty rota reflected the number of staff on duty. The residents, staff and relatives spoken with felt that there were always enough staff on duty to look after them properly. Three staff files were looked at by the inspector and the required information was complete in all of them. This included evidence of identification, adequately completed application forms, two written references and Criminal Records Bureau checks. There were records of staff training including induction and the staff spoken with confirmed that they received regular training in moving and handling. They said that they had training in first aid, food hygiene and medicine training. There is a record of training held by the manager with the certificates in the staff files. Broadoak Grange DS0000001648.V340325.R01.S.doc Version 5.2 Page 22 The home has four members of staff with a National Vocational Award (NVQ) at level 2 or above, this is 25 of the stafff, which is below the minimum required standard. There are another five members of staff enrolled on an NVQ. This will bring the percentage of staff well above the minimum stanadard of 50 . The acting manager has completed a level 4 in care and is now working towards the registered managers award through the National Vocational Award programme. The National Vocational Qualification is a qualification for care staff to make sure that they receive the right training in the needs of the resident group whom they are caring for. The acting manager told the inspector that he had arranged English classes for those staff who had language difficulties. The staff now had a good understanding of English or had left the home. All the staff spoken with or seen with the residents had good language skills. The residents and families all said that they had no difficulties in understanding or being understood by the staff. Broadoak Grange DS0000001648.V340325.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, 32, 33, 35, 36, 37, 38.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The acting manager is committed to the best care for the residents through training, good communication and thorough recruitment practice. EVIDENCE: The acting manager was available throughout the visit to the home. The acting manager has been in post for over a year and has not yet registered with the Commission for Social Care Inspection (CSCI). An application should be made to the CSCI to be approved to be registered as the manager. This is a process to make sure that the proposed person is a ‘fit’ person to become a registered mangaer. Broadoak Grange DS0000001648.V340325.R01.S.doc Version 5.2 Page 24 He has completed an NVQ at level four and is working towards his registered managers award. The acting manager is committed to the improvement of the home and has made a lot of progress in raising the standards. There was no evidence that regular staff supervision was in place, although, there were records of staff appraisal having been completed. The members of staff spoken with confirmed that they had not received supervision. The process of formal supervision time gives the staff and their ‘line manager’ the opportunity to have individual discussions about work and training needs. There are regular meetings held with the staff group to pass on and exchange information. The manager meets regularly with the residents and their families as well as having one to one discussions, both to pass information on and to listen to their views and opinions. There are annual quality questionaires sent out to residents and their families to gain their views about the home. These practices allow the manager and the responsible person to respond to the residents and the staff’s needs. There are accounts held to manage the residents personal allowances and are being managed correctly with two signatures and the receipts in place. The policies and procedures are in place for the home and are regularly reviewed. They are available for the staff to read to make sure that they know how the residents are to be cared for. Records for the maintenance of fire equipment, fire drills and training were found to be in place and up to date. The registered provider completes a provider report (Reg 26) every month and there is a copy kept in the home. Broadoak Grange DS0000001648.V340325.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 3 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X 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 3 3 3 X 3 2 3 3 Broadoak Grange DS0000001648.V340325.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 (1)(a)(b) (c) Requirement 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. Timescale for action 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations That a thorough pre assessment document is produced and that all prospective residents are assessed before moving into the home to make sure that their needs are known and can be met. That the plan of care is discussed with the resident and/or their family and a signature is obtained to signify their agreement. That the practice of pre dispensing night- time medicines stops and a safe alternative method of giving them is found. DS0000001648.V340325.R01.S.doc Version 5.2 Page 27 2. 3. OP7 OP9 Broadoak Grange 4. 5. 6. OP9 OP18 OP36 That the chemist is asked to supply pre-printed labels for all medicines. That all the staff receive training in safeguarding adults and instruction in how to deal with complaints. That all the staff have formal supervision at the frequency required by the care standards act. Broadoak Grange DS0000001648.V340325.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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.V340325.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. 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