Inspection on 06/07/06 for Danesford Grange Care Home

This inspection was carried out on 6th July 2006.

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

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

Other inspections for this house

Danesford Grange Care Home 30/06/08

Danesford Grange Care Home 27/07/07

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Danesford Grange Care Home Kidderminster Road Bridgnorth Shropshire WV15 6QD Lead Inspector Joy Hoelzel Key Unannounced Inspection 6th July 2006 07:45 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.V297435.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.V297435.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 Mrs 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.V297435.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Mrs Thomas must remain supernumery in her role until the appointment of a Deputy Maximum number of beds can only be thirty three (33) of which three (3) beds may be for dementia care. 28th October 2005 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. It is privately owned and located on the outskirts of Bridgnorth, on the main road to Kidderminster. Weekly fees range from £460:00 - £600:00. 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. Danesford Grange Care Home DS0000022250.V297435.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection is the first of key inspections for 2006/07 and took place over seven and three quarter hours on Thursday 6th July 2006. It was conducted by one Commission for Social Care Inspection regulation inspector. Twenty seven of the thirty eight National Minimum Standards for older people were inspected. Thirty one people are currently living at the home staffing levels appeared to be satisfactory. The matron was on the premises and was supported by two nurses, five care staff, finance manager, administrator and ancillary staff. The ladies and gentlemen were observed to be in all areas of the home and garden engaging in various daily activities. What the service does well: What has improved since the last inspection? A walk in shower has been installed offering service users a choice of bathing facilities. A sluice disinfector has been purchased. Some redecoration has taken place and replacement carpets have been fitted. The home now offers an additional service for up to three people with dementia and/or cognitive difficulties. Danesford Grange Care Home DS0000022250.V297435.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Danesford Grange Care Home DS0000022250.V297435.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Danesford Grange Care Home DS0000022250.V297435.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 1,3, 6 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. The information provided to current and prospective service users is presented in an exemplary clear manner enabling them to make a properly informed choice about the home. EVIDENCE: The home has recently reviewed and revised the statement of purpose and service user guide (December 2005); both documents are readily available and contain all current information in a concise and comprehensive way. Care home surveys were distributed to service users and visitors at the time of the inspection of which eleven were completed and returned. Nine people indicated on the survey that they had received enough information about the home prior to making the decision to move in. Only one person did not have information the reason being that she came to the home on an emergency basis. The manager or a member of senior staff conducts pre admission assessments of a persons needs before a placement is confirmed. Comments in the survey indicated that the family are invited to visit the home with the prospective Danesford Grange Care Home DS0000022250.V297435.R01.S.doc Version 5.2 Page 9 service user whenever possible. One person commented ‘ I was visited by Matron before I came in’. Other assessments from the outside agencies are obtained prior to admission and copies are kept in the case file of the individual. The pre admission assessments are used to generate an initial plan of care at the point of admission. The home has does not provide an intermediate care service. Danesford Grange Care Home DS0000022250.V297435.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 7,8,9,10 Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are sensitive to the individual needs of each service user and meet these in a professional manner. Improvements have been made to the procedures for the administration of medication, however the storage of medication continues to be problematic. EVIDENCE: Four case files were selected for inspection and included the care plan for the person who had most recently moved to the home. All four files were set out uniformly, were easy to read and follow. The plans are reviewed at least monthly or when a change of need has been identified. Service users and their representatives are invited and encouraged to be fully involved in the process but it is acknowledged that some service users are too frail or do not wish to be involved. A letter inviting a relative to a care review had been returned to the home declining the invitation but with an additional comment ‘ I am very happy with the care and attention my relative receives but should there ever be a problem please let me know’. Two of the case files contained very good information for recognising the symptoms of pain and described the ten signs to look for to assess pain when a person is unable to verbally communicate. Danesford Grange Care Home DS0000022250.V297435.R01.S.doc Version 5.2 Page 11 During the tour of the premises a high proportion of service users in the nursing category were observed to be extremely frail, bed bound and unable to communicate adequately their needs. The matron explained that more extremely frail people are being referred to the home for nursing care. Two case files contained a comprehensive risk assessment for the safe use of bedrails. Following an incident where a service user tried to climb over the top of the bedrail during the night, the care plan and risk assessment has been amended and action taken to reduce the risk of a reoccurrence. A daily report stated that a problem had been identified with pressure area care on 12/06/06 with comments made at intervals in the daily report. A care plan had not been developed for this problem, the matron agreed that a plan of care should have been developed but hadn’t, and that she would attend to it immediately. Some risk assessments and screening tools had not been fully completed for the plan of care for the person who had most recently moved in. The matron demonstrated a computer programme recently acquired by the home for maintaining all records that are required. All staff will be given training on how to use this programme. The home operates a twenty eight day regime for medication administration using a blister type package with the additional use of bottles and boxes. Improvements have been made to the procedures for the safe administration of medication. Three requirements have not been fully complied with following the pharmacy inspectors report following the visit 5th May 2005. The temperature of the dedicated medication fridge is being recorded on a daily basis apart from the last two days the temperature remained at a constant level of between 2 – 8 degrees Celsius. The nurse explained that due to a temporary power cut two days previous; the minimum temperature has been recorded at 1 degree Celsius. Monitoring will continue with action to be taken to maintain the correct temperature. The security of the control drugs cabinet and the medication fridge is still an issue as they are both located at the nurses station in Elm unit. The matron and finance manager explained the difficulties with relocation, as an appropriate site cannot be identified. Only one person is currently self medicating, a lockable space has been made available for the safe storage of his medications and an assessment of risk has been carried out, the review of which is due shortly. During the tour of the premises privacy indicators have been fitted to communal bathroom and doors, however most doors still do not have a suitable and appropriate locking facility. A sign has been fitted to all bedroom doors reminding people to knock and wait before entering private accommodation. Staff were observed to be carrying out tasks and personal interventions in a discreetly and in a manner which promote service users’ dignity. Danesford Grange Care Home DS0000022250.V297435.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 12,13,14,15 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. The daily life and social activities arranged for service users takes into account the differing expectations, preferences, lifestyle and capacities of each individual. EVIDENCE: Two staff members are allocated time for arranging and organising social and leisure activities both in house and in the community. Entertainers are arranged to visit the home on occasions throughout the year. One service user stated that he enjoyed a game of bingo, this is arranged each week. The matron explained the plans for attending the local Bingo hall and felt this would be a beneficial and an enjoyable experience. Three people indicated in the survey that they never took part in the activities that are arranged making comments ‘ unable to take part due to illness… it is my choice’, ‘I am asked by staff but like my own company, do not like to mix much’. Other service users stated that they enjoyed the activities and that they were sufficient to their needs, only one person stated that at times he would like to have ‘more going on’. Danesford Grange Care Home DS0000022250.V297435.R01.S.doc Version 5.2 Page 13 Relatives and friends are welcome to visit the home and details of visiting time are included in the statement of purpose. Many people were visiting at the time of the inspection. Three people stated that they visit at least three times a week and always felt welcome. Staff had arranged for one visitor to have lunch with her relative, and stated that this is a regular occurrence and something that she enjoyed. A Church of England minister visits the home each month to offer communion, the minister will meet with people in private if they so wish. During the tour of the premises many of the bedrooms were individualised with personal belongings. Staff were observed to be offering choices to service users throughout the day, the choices and options very much dependent on the capacity of the individual. Meals are served to service users either in the communal or private areas as to the preferences of the individual. Usually the dining areas in the main lounge are set for meals but on the day of the inspection the main lounge was out of action due to a new carpet being laid. Five people who completed the survey indicated that they liked the food offered, only one person made an additional comment ‘institutional food, ok, as far as it goes’. Visitors stated that they thought the meals were very good ‘ always a good lunch and a lovely dessert’. Alternative diets can be available when the need arises. Snacks and drinks are also available throughout the day and night. Staff were observed to be assisting with meals in an acceptable and relaxed manner. Danesford Grange Care Home DS0000022250.V297435.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 16,18 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. Concerns or complaints are dealt with promptly and professionally and the arrangement for the protection of residents from abuse is satisfactory. EVIDENCE: The complaints procedure is included in the statement of purpose; a copy is also displayed on the notice board at the entrance to the home. No complaints have been sent directly to Commission for Social Care Inspection since the inspection in October 2005. The matron discussed the findings of one complaint raised directly with the home. A full investigation was carried out and the complainant was satisfied with the outcome and explanations. A relative/visitors comment card has been received, and indicated ‘my complaint was dealt with positively’. A copy of the local multidisciplinary procedures for Shropshire is available, as are the homes own policies and procedures for dealing with adult protection issues. Abuse awareness is included in the induction programme for all employees and further training is being arranged in this area. One service user stated that they did not know about the complaints form but felt that if there were any concerns they would ask to see the matron. The procedure for the care and storage of client’s money is included in the statement of purpose. It is recommended that the home state the maximum amount of cash for which they will hold for safekeeping is included in this procedure. Danesford Grange Care Home DS0000022250.V297435.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 19,20,21,22,24,25,26 Quality in this area is poor but improving. This judgement has been made using available evidence including a visit to this service. Although some improvements have been made to the environment and some new equipment purchased, additional investment is required to maintain and further improve the standards for the current service users group. The lack of basic facilities continues to undermine privacy and dignity standards. EVIDENCE: The finance manager and matron discussed the future plans for further developing the home, with more bedrooms and improved communal areas. A programme for the routine maintenance and redecoration of the existing building is nevertheless required, to maintain standards. During the tour of the premises some areas were looking ‘tired’ and in need of attention. The fire officer visited 18th February 2005; the administrator confirmed that all the recommendations have been complied with. A copy of the fire risk Danesford Grange Care Home DS0000022250.V297435.R01.S.doc Version 5.2 Page 16 assessment is dated 20/08/04 and is now requiring revision and review. The finance manager was advised to contact the local fire inspection officer for advice. The manager stated that two overseas adaptation nurses are temporarily living in a room on the second floor of the building. A risk assessment is urgently required to be undertaken. Two wooden blocks were observed to be in use keeping open identified fire doors. These were discarded immediately; the manager and matron were advised to install a self-closing device where there is a need or preference for doors to remain open. One service user was sitting in the garden enjoying his cigarettes and stated that he enjoyed being in the garden weather permitting. The finance manager discussed the plans for improving certain areas around the garden making them more ‘user friendly’. The walk in shower has been installed; this offers service users another choice of bathing facilities. A relative/visitor comment card has been received with the additional comment ‘wonderful new shower which is being enjoyed’. Bed rails are provided on beds where there is an assessed need for this equipment. During the tour of the premises a sample of the bedrails appeared to be well fitted to the beds, bumpers are supplied and in use for added protection for the service users. A problem with the level of noise from the call bells was identified during the quality audit undertaken 2005/06. During the inspection the call bells were heard to be loud and intrusive, one service user stated that particularly at night the sound of the bells can be very disturbing. It is acknowledged that the call bell system is essential and must be operational at all times. The agreement of the offer of a lockable facility on service users private rooms has been included in the care plan which has been signed by the service user and/or representative. The door locking facility must be available on all private bedrooms so as to offer a true choice to each service user of having their door locked or not. This is outstanding from two previous inspections and the agreed date of compliance of 31st November 2005 has not been met. Not all bedrooms have been provided with comfortable seating for two people, most service users are satisfied with the amount of furniture provided, however the resident of Room 1 requested an additional chair for when she has visitors. This was discussed with the matron and a chair will be provided. An automatic sluice disinfector has been purchased and is on the premises. It is recommended that a contractor be contacted to fit the machine. Danesford Grange Care Home DS0000022250.V297435.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 27,28,29,30 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported and protected by the homes recruitment policy and practices. EVIDENCE: Staffing levels are maintained in line with the minimum requirements and a rota is kept. A relative/visitor comment card has been received with the additional comment ‘ staffing has been a problem but is better at the moment- everyone works very hard’. At least one registered nurse is on the premises over the twenty four hour period, supported by care and ancillary staff. The manager commented that the home is presently fully staffed with no vacancies. The statement of purpose states that the home strives to achieve 75 of care staff are trained to National Vocational Qualification levels 2 and 3. Staff commented that they found the training to NVQ level very interesting and assisted them to improve the care they offer to service users. Three staff personnel files were selected for inspection each contained references, identity checks and criminal record bureau disclosures. Training and development undertaken are recorded on a training matrix with copies of any certificates received kept in the personnel file. Training in dementia care is included in the induction programme for all staff. Danesford Grange Care Home DS0000022250.V297435.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP 31,33.35,38 Quality in this area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by a competent manager who leads the staff group with confidence. Staff are clear about roles and responsibilities. EVIDENCE: The manager is a qualified nurse with the skills and experience to manage the home on a day-to-day basis. She is supported by the finance manager and stated that she feels that the home ‘is running well’. The manager has gained the Registered Managers Award and has recently attended a course on manual handing and is now the nominated in-house trainer in this area. The manager demonstrated a good knowledge of the service users group and the conditions and diseases associated with ageing. Danesford Grange Care Home DS0000022250.V297435.R01.S.doc Version 5.2 Page 19 The results and comments received from last years quality assurance and monitoring systems are included in the statement of purpose. Satisfaction questionnaires are sent out periodically to service users, relatives and staff. Monthly meetings are arranged for service users and staff. The procedures for the safekeeping of service users monies and valuables appear robust, with the person in charge of the shift allocated the responsibility for any transactions that are required. Observation of the record and amount of actual cash held on the premises on behalf of service users corresponded correctly. Two signatures are obtained for each transaction and receipts are kept. Records for the regular monitoring of equipment e.g. fire safety, water temperatures, emergency lighting, portable appliance tests were all up to date. As previously mentioned in the report the homes fire risk assessment is now well out of date and requires urgent attention. Danesford Grange Care Home DS0000022250.V297435.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 2 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 2 3 3 3 X 2 X 2 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 X 3 X 3 X X 2 Danesford Grange Care Home DS0000022250.V297435.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP8 Regulation 12(1)(a) (b) 12(1)(a) (b) Requirement A full plan of care must be developed following identification of potential difficulties with maintaining skin integrity. All risk assessments and screening tools must be fully completed at the point of admission and reviewed at intervals. The maximum and minimum temperatures of the medication fridge must be recorded to maintain a temperature at between 2 and 8 degrees Celsius. Previous requirement not fully met. Security for the controlled drugs cabinet and the medication fridge must be improved. Previous requirement not fully met. The controlled drugs cabinet and the register must be audited on a daily basis to ensure that service users are receiving their medication correctly. Previous requirement not fully met. DS0000022250.V297435.R01.S.doc Timescale for action 31/07/06 2 OP8 31/07/06 3 OP9 13(2) 31/07/06 4 OP9 13(2) 31/08/06 5 OP9 13(2) 31/07/06 Danesford Grange Care Home Version 5.2 Page 22 6. OP10 12(4)(a) The registered person must ensure that each toilet and bathroom door has a suitable locking facility to ensure a person’s privacy and dignity is upheld. Previous timescale 30/11/05 not fully met. 31/08/06 7 8 OP19 OP19 23(4)(5) 23(4) 9. OP24 12(4) The home must ensure that a full 31/07/06 and comprehensive fire risk assessment is undertaken. Doors to communal and private 31/07/06 areas must not be wedged open with wooden blocks or pieces of furniture. Doors to service users private 31/08/06 accommodation must be fitted with locks suited to service users capabilities and accessible to staff in emergencies. Previous timescale 30/11/05 not met. Risk assessments must be carried out for all safe working practice topics. 31/08/06 10 OP38 13(4)(c ) 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 Refer to Standard OP26 OP22 Good Practice Recommendations It is recommended that a contractor be contacted to fit the automatic sluice disinfector. It is recommended that consideration be given to the identified problems with the noise level of the call bell system. Danesford Grange Care Home DS0000022250.V297435.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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