Inspection on 30/06/08 for Danesford Grange Care Home

This inspection was carried out on 30th June 2008.

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

Danesford Grange Care Home 27/07/07

Danesford Grange Care Home 06/07/06

Danesford Grange Care Home 28/10/05

Danesford Grange Care Home 20/04/05

Danesford Grange Care Home 22/03/05

Danesford Grange Care Home 17/08/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Danesford Grange Care Home Kidderminster Road Bridgnorth Shropshire WV15 6QD Lead Inspector Rosalind Dennis Key Unannounced Inspection 30th June 2008 09:00 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 Danesford Grange Care Home DS0000022250.V367134.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. Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Danesford Grange Care Home Address Kidderminster Road Bridgnorth Shropshire WV15 6QD 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) 01746 763118 01746 767551 danesfordgrange@ukonline.co.uk Mr Michael Blandy Mrs Gwendoline Blandy Miss Joan Thomas Care Home 33 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (33) of places Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Maximum number of beds can only be thirty three (33) of which three (3) beds may be for dementia care. 27th July 2007 Date of last inspection Brief Description of the Service: Danesford Grange is a care home providing accommodation, personal and nursing care for thirty three older people, of whom three may have dementia related illness. It is privately owned and located on the outskirts of Bridgnorth, on the main road to Kidderminster, and can be accessed via a local bus route. The property consists of an older building and an extension, which has been added in recent years. It is set back from the road in its own grounds. Countryside views can be enjoyed from most elevations of the property. The accommodation is laid out over four levels each being named after trees and accessed by a passenger lift. The home has both single and double bedrooms, some of which have en suite facilities provided. The home management team makes the services of Danesford Grange known to prospective residents in their statement of purpose, and its brochure/service user guide. Information on fees is included within the service user guide, where it is noted that prices vary according to the needs of the individual. Weekly fees for people who fund their own care are documented as around £400 for personal care (residential) to a minimum of £500 per week for people requiring nursing care. The reader is advised to contact the home to obtain up date information on the fees charged. People can obtain information about this service from the home’s Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on CSCI’s website at www.csci.org.uk. Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was conducted by one inspector over a period of around 7 hours. All ‘key’ standards were assessed during the daythat is those areas of service delivery that are considered essential to the running of a care home. During the inspection we spoke with people living at the home, visitors, staff and the manager, Jo Thomas who was on duty for the duration of the inspection. Time was spent observing and finding out how people spend their days and looking at the interactions between staff and people living at the home. We also looked at care records and other documentation and observed a selection of bedrooms and communal areas. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was sent to the home for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for providers to share with us areas that they believe they are doing well. It is a legal requirement that the AQAA is completed-Danesford Grange returned their completed AQAA to us within the given timescale. Information within this document gives a reasonable picture of the current situation within the service and shows that the manager has some ideas for improving the service to benefit people living at the home. What the service does well: Danesford Grange has a good assessment and admission procedure, which ensures that people are only admitted to the home if the service is confident that it can meet their needs. Care planning focuses on the individual needs of people living at the home and provides staff with the information they require to meet people’s needs. People living at the service are able to enjoy a range of activities and people are provided with nutritious meals. Danesford Grange provides people with a comfortable and clean place to live. Training opportunities for staff are good and the home ensures there are sufficient staff on duty to meet people’s needs. Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Discussions with the manager and finance manager during the inspection demonstrated an awareness of where improvements need to be made, with reassurances that action would be taken. An area which has been an outstanding requirement for sometime is the fitting of ‘privacy locks’ to individual bedroom doors, the home acknowledges this has not yet been achieved but is aware that it must be completed to provide people with a choice as to whether they want to lock their bedroom doors. The process of staff supervision doesn’t meet all the elements expected of ‘formal supervision’, such as reflection on practice and training and development needs. We were informed that the manager has recently undertaken training in conducting supervision and information we received after the inspection shows the manager’s intention to introduce changes to improve the staff supervision process. An area, which the home must take action on, is to ensure that any staff involved in the fitting of bed rails are competent to perform this task. During the inspection we gave information on where to locate relevant guidance on the safe use of bed rails and we received confirmation after the inspection that the home has obtained this guidance. The home is also advised to ensure all staff are aware of the guidance, so that they can readily identify any problems. Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Danesford Grange has a good assessment and admission procedure, which ensures that people are only admitted to the home if the service is confident that it can meet their needs. EVIDENCE: During this inspection we looked at the care records for three people recently admitted to the home and this shows that the manager or another senior member of staff, conducts detailed assessments of people’s needs prior to and on admission to the home. These assessments show that the home seeks detailed information from the person awaiting admission and from their significant others about their individual care needs and matters which are important to them such as their hobbies, dietary preferences, cultural and religious needs –observation of care plans shows that this information is then used to plan the person’s care. Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 10 Observation of a copy of one person’s terms and conditions for the home shows that this contains individualised information on fees. The home’s statement of purpose and service user ‘welcome guide’ is available in the reception area along with an assortment of informative leaflets about supportive services. The service user guide is easy to read and people were aware of the documents content and had their own personal copy. At the time of inspection the guide needed more information on the range of fees charged by the home-an amended copy was sent through after the inspection, which shows that people are now provided with this information within the content of the guide. One person who was able to communicate his needs spoke of his satisfaction with how the home asked about his individual needs and wishes at the time of his admission and that the care he receives is based upon this. Relatives of another person spoke of their satisfaction with how the manager and staff consulted with them on their relative’s admission and made them feel welcome. Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are clear and focus on the individual needs of people living at the home and provide staff with the information they require to meet people’s needs. EVIDENCE: Since the last inspection the home has looked at ways to ensure people or their significant others are involved in care planning and provided with information on how individual needs will be met. Copies of people’s care plans are now available in their rooms and people spoken with during inspection viewed this as a positive move, so that they are able to see how the home intends to meet their needs. People visiting also spoke of how they also like to look at their relative’s care plans. Time spent with one person demonstrated that the care plan was an accurate reflection of their needs and for another person who needs assistance to mobilise, the care plan clearly stated equipment and numbers of staff needed to safely support them to mobilise. Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 12 The home uses a computerised system to maintain people’s care records and staff view this as an effective process, enabling care plans and other documentation to be updated quickly. All of the care plans we looked at, were clear, up to date and reviewed regularly, providing information to staff on how to meet each persons needs including mental health, personal care, mobility, safety, and social care needs. A range of risk assessments provides additional information on any recognised or potential risks to the individual. Observation of a selection of medication administration records (MAR) charts, showed that medication had been recorded accurately with all medication signed and accounted for. One area which was discussed is the way medication is given out to people, the current process is for a carer, trained in the safe administration of medicines, to take and give medication which has been dispensed by the nurse, the carer then signs the MAR chart. The home has sought advice and guidance on this practice and we discussed an ongoing need for the home to be clear that it has a robust audit trail in place. People who were able to communicate their views provided some very positive comments about how their needs are met at Danesford Grange. People who, because of their illness were unable to speak with us, looked clean and comfortable. Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 13 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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the service are able to enjoy a range of activities, which are based on their capabilities and preference. The meals at the home are good and cater for different nutritional needs. EVIDENCE: People spoken with during the inspection were happy about the range of activities provided at Danesford Grange. One person spoke of how he takes part in an exercise class and was seen participating in this class during the afternoon of the inspection. The home informs people of entertainment provided by way of the service user guide and also puts up information on forthcoming events on notice boards. For people who are less able to participate in group activities and events, the home provides more individualised activities such as hand and body massage. A person recently admitted to the home spoke of how the cook had visited him soon after admission to find out his dietary preferences and he viewed that all meals he had eaten since his admission were of a good standard. Menu’s on Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 14 display in dining areas provide people with a week by week view of meals. The home does not include a choice of meals within the menu, one person commented on a lack of menu choice but was aware that the home provides alternatives to the menu and he had liked all the meals so far. Time spent in one of the dining areas found that people appeared to enjoy their meals with appropriate assistance provided by staff. Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 15 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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. If people have concerns with their care, they or people close to them know how to complain. Staff are provided with training to equip them with the knowledge and skills to safeguard adults from the risk of abuse or neglect EVIDENCE: The complaints procedure is included in the statement of purpose and service user welcome guide; a copy of the procedure is also displayed on the notice board in the reception and in other locations around the home. People living at the home and their relatives were aware of the procedure and all people spoken with confirmed they feel comfortable raising any concerns with the manager or other staff. Information provided by the manager shows that the home has received 3 complaints in the last twelve months, and records show the complaints have been acted on appropriately. A copy of the local area adult protection policy is available, as are the homes own policies and procedures for dealing with adult protection issues. The manager is aware of the Mental Capacity Act (MCA) 2005 and has updated care documentation to reflect issues which may arise when people may not have full capacity to make decisions. Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 16 Observation of staff records shows that training in adult protection/abuse awareness is provided to staff at the time of their commencement of employment at Danesford Grange and on an ongoing basis. Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 17 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, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Danesford Grange provides people with a comfortable and clean place to live. EVIDENCE: During the inspection we looked at a selection of bedrooms and communal areas, which confirms that the home has continued with a programme of redecoration and refurbishment, including the fitting of some new carpets. Parts of the home still need attention, however this appears to be in hand and is noted within the manager’s plans for improvement over the next twelve months. An outstanding requirement for sometime has been the fitting of locks to people’s bedrooms doors, observations made at this inspection shows that this is work in progress with most rooms now having this facility and the manager confirmed that the remaining locks will be fitted. Provision of ‘privacy locks’ provides people with a choice of locking their bedroom doors and staff Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 18 were seen during the inspection locking people’s doors whilst providing care tasks. The home looked clean and observations of care staff working confirm that staff follow appropriate guidance in relation to infection control. Staff confirmed they receive training in infection control. The call buzzer sounded several times during the inspection and was attended to promptly by staff. The call buzzer is notably high pitched, however none of the people who were spoken with at the time of this inspection identified it as a problem, therefore the home needs to keep this under review and take action if people are disturbed by the noise. The garden on the day of inspection was well-maintained. Information provided by the manager describes how the home has recognised that improvements could be made to enhance the garden, such as the provision of raised flower beds and is continuing to look at ways to fund such a project. Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 19 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are provided with good training opportunities and feedback from people indicate that most staff put these skills into practice to meet individual needs. The recruitment procedure is robust and protects people from the employment of inappropriate staff. EVIDENCE: People who were spoken with during the inspection felt that there are enough staff on to meet their needs. Three staff who were spoken with consider that the current staffing levels are sufficient to meet people’s needs safely and promptly. Variable start times of staff shifts helps to ensure additional staff are around at busier times of the day. Staff commented positively regarding training opportunities within the home and viewed the manager as supportive and approachable. One staff member showed their individual training record as an example of the wide range of training they had undertaken and observation of a training ‘planner’ shows that all staff are provided with good training opportunities on a regular basis. Information provided by the manager confirms that some staff have already attained a recognised qualification in care (NVQ Level 2), some are in the process of studying for Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 20 NVQ 2 with other staff planned to undertake this training and at different levels. Since the last inspection the home has had a number of staff leave and new staff start; we looked at two personnel files for new staff, which contained all the required pre-employment checks confirming that the home operates a robust recruitment procedure. Staff are provided with a comprehensive induction and on completion of this are given opportunity by way of questionnaire to comment on the process and whether it has helped prepare them for their new role. Although we received positive feedback about the care provided at the home, two relatives and two people living at the home spoke of how some staff are better than others in respect of their abilities at attending to people’s needsthis was shared with the home so that this could be monitored and acted upon as necessary. Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 21 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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager, Jo Thomas has the skills and knowledge to manage the home and lead the staff team to ensure that outcomes for people living at the home are now good. EVIDENCE: People living at the home described how the registered manager Jo Thomas speaks with them on a regular basis and listens to what they have to say. Jo Thomas was on duty for the duration of the inspection and demonstrated a good knowledge of the varying needs of people living at the home. For the purpose of this inspection the manager had responded to a request by the Commission to complete an annual quality assessment document (AQAA)information within this document gives a reasonable picture of the current Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 22 situation within the service and shows that the manager has some ideas for improving the service to benefit people living at the home. People and their representatives are provided with opportunities to comment on different aspects of the service through questionnaires, results of which are then collated and an action plan developed. Staff commented on how they find staff meetings useful and also confirmed regular supervision. Observation of supervision records shows that the manager is supervising staff practice, which is positive but doesn’t meet all the elements expected of ‘formal supervision’, such as reflection on practice and training and development needs. We were informed that the manager has recently undertaken training in conducting supervision and information we received after the inspection shows the manager’s intention to introduce changes to improve the staff supervision process. The service user guide includes the home’s procedure regarding the safekeeping of people’s monies and during the inspection we looked how the home maintains records of individual financial transactions and this appeared robust. Observation of how the home reports accidents and incidents shows improved reporting and any follow up action is now recorded. The manager provided information within the AQAA that servicing and maintenance of equipment is undertaken and policies and procedures are regularly reviewed. Observation of the fire safety ‘log book’ shows that fire safety checks are up to date. During a tour of the home we observed that a fire door has been replaced and the finance manager confirmed that the home is continuing to work towards meeting the requirements and recommendations identified in the last fire officer’s report-this work needs to be completed without delay as it is almost twelve months since the fire officer visited. Bedrails, which were observed in use were fitted correctly, one rail was noted to have a missing part and this was brought to the attention of the administrator for action to be taken. Records are kept to show that bed rails are audited monthly, although discussions with the manager indicated that the staff who perform the audits have undertaken training in Health and Safety, the manager was not aware whether their training incorporated bed rail safety. A concern in respect of staff competency in the fitting of bed rails was identified during our inspection in July 2007. Information on where to locate relevant guidance on the safe use of bed rails was given to the manager and finance manager during this inspection; the home must ensure that any staff involved in the fitting of bed rails are competent, it is also good practice to ensure all staff are aware of the relevant guidance, so that they can readily identify any problems. Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 23 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 24 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 OP38 Regulation Requirement Timescale for action 15/08/08 13 (4) (c ) The home must ensure that staff who assess, fit and maintain bed rails do so in accordance with MHRA and HSE guidance and are competent at this task. This is to protect people from the risk of harm and promote their safety. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Danesford Grange Care Home DS0000022250.V367134.R01.S.doc Version 5.2 Page 26 - 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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