Inspection on 01/08/07 for East Dean Grange

This inspection was carried out on 1st August 2007.

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

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

Other inspections for this house

East Dean Grange 21/07/08

East Dean Grange 14/09/06

East Dean Grange 01/12/05

East Dean Grange 13/07/05

East Dean Grange 22/11/04

East Dean Grange 04/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE East Dean Grange Lower Street East Dean East Sussex BN20 0DE Lead Inspector Elizabeth Baker Key Unannounced Inspection 1 August 2007 09:50 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 East Dean Grange DS0000021090.V345614.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. East Dean Grange DS0000021090.V345614.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service East Dean Grange Address Lower Street East Dean East Sussex BN20 0DE 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) 01323 422411 01323 422412 Simpsonn@Bupa.com www.bupa.co.uk BUPA Care Homes (CFC Homes) Limited Mr William Simpson Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places East Dean Grange DS0000021090.V345614.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is 33 (thirty three) The care home can provide personal care to older people aged 65 (sixty five) years or over on admission 14th September 2006 Date of last inspection Brief Description of the Service: East Dean Grange provides care for up to 33 older people requiring personal care. The home offers hotel style accommodation in a large detached country house situated in the village of East Dean approximately four miles from Eastbourne. The home is close to the church, village hall and public house. There is a four-person passenger lift and a chair lift that provide access to most areas except for three bedrooms in the older part of the building. All bedrooms are en-suite and decorated to a high standard. There is a communal shower. Other facilities include a variety of sitting rooms, a terrace, a drinks bar, a split-level dining room and an indoor swimming pool. The home is surrounded by well-maintained gardens and there are ample car parking facilities. All bedrooms are connected to the call alarm system, have cable TV and fitted with telephone points. Fees currently range from £788.00 to £998.00 per week, depending on need and bedroom to be occupied. These fees are inclusive of a twice-weekly taxi trip to Eastbourne. Additional charges are made for individual newspapers, visitors’ meals, bar drinks, chiropody, hairdressing, physiotherapy and telephone calls. The latest edition of the home’s inspection report is kept in the reception area. Current activities include art, quizzes, movement to music, talks of special interest, classical music and bingo. East Dean Grange DS0000021090.V345614.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first key unannounced visit to the home for the inspection period 2007/08. Link Inspector Elizabeth Baker carried out the visit on the 1 August 2007. The visit lasted just over eight hours. As well as briefly touring the premises, the visit consisted of talking with some residents and staff. Four residents and two members of staff were interviewed in private. Verbal feedback of the visit was provided to the Senior Carer acting as home manager. The registered manager was absent on annual leave. At the time of compiling the report, in support of the visit, the Commission received survey forms about the service from eight residents, five relatives/advocates and four health care professionals. At the Commission’s request the registered manager completed and returned an Annual Quality Assurance Assessment (AQAA). Some of the information gathered from these sources has been incorporated into the report. At the time of the visit 27 residents requiring personal care were residing at the home. The Commission has not received any complaints about the service. What the service does well: The atmosphere around the home was calm and quiet. Residents appreciate this. The home and grounds are maintained to a very good standard, providing residents with a homely environment in which to live. Comments from residents and their relatives/advocates included “each resident is treated with the utmost respect”; “overall I am very satisfied with the facilities and care provided”; “staff are always very kind, ask what is wanted and meals have been excellent”; “the most important skill is not to patronise elderly people who need residential care and this was what impressed me about all the staff at East Dean Grange – they never patronise”; “East Dean provides a home from home atmosphere in a very relaxed and thoughtful way”; “Excellent food – more imaginative menus now since new chef started” “the home has a very nice atmosphere about it”; “I like the location of the home as it is quiet but not isolated and not deafened by traffic” and “Staff are friendly and most helpful”. The provider supports staff in obtaining qualifications and accessing training. Indeed 75 of carers have attained NVQ level II or above in care, exceeding the national minimum standards for care homes. East Dean Grange DS0000021090.V345614.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. East Dean Grange DS0000021090.V345614.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 East Dean Grange DS0000021090.V345614.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6. Residents who use the service experience good quality outcomes. This judgement has been made using a range of evidence including a site visit to this service. Systems are in place to determine prospective residents’ suitability to be admitted into the home, although more recorded detail and enhanced documents would enhance the process further. EVIDENCE: Residents are provided with a contract setting out the terms and conditions of staying at the home. The document sets out the rules and responsibilities of both parties. In addition to contracts, prospective residents are provided with a colour brochure giving a brief insight into the home’s environment and services. To supplement this a Statement of Purpose has been developed. However it does not specifically detail the home’s environment including precise details of the en suite facilities and the one assisted shower room. The Statement of Purpose also refers the reader to the organisation’s policies and manual, as well as to the National Minimum Standards. This situation prevents a clear picture of the home’s services, practices and facilities being easily East Dean Grange DS0000021090.V345614.R01.S.doc Version 5.2 Page 9 accessed. As a welcoming gesture flowers and a basket of fresh fruit are put into the bedrooms of new residents. Prior to admission residents are generally assessed as to their suitability of being cared for at this home. Details should be recorded. However in the case of one resident returning for a second respite stay, there was no recorded evidence a second assessment to reflect their changed condition had been done. The home is not registered for intermediate care. Standard 6 is not applicable. East Dean Grange DS0000021090.V345614.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Residents who use the service experience adequate quality outcomes. This judgement has been made using a range of evidence including a site visit to this service. The health and personal care needs of residents are generally meet with evidence of multi-disciplinary working taking place when required. However some residents are potentially at risk because care documentation in support of this is somewhat lacking. EVIDENCE: For case tracking purposes the care records of four residents were inspected. However one of the residents had not yet been provided with a care plan. The resident was admitted into the home in April 2007. The home uses a range of risk assessments to assess and monitor potential risks to residents. Not all the records seen contained the requisite assessments to monitor the identified risks. This included moving and handling, nutrition and falls prevention. Indeed for a resident currently receiving treatment for a potential pressure sore, there was no corresponding skin integrity risk assessment. And for a resident with a low body weight, there was no evidence the resident had been re-weighed since admission. Daily records are maintained for staff to East Dean Grange DS0000021090.V345614.R01.S.doc Version 5.2 Page 11 complete as evidence of the care and support required and that delivered. These were signed, dated and timed. Some contained a good mix of comments providing a picture of the residents’ quality of day. However not all the records had been completed on a daily basis. This could present problems if the records were needed to be produced as evidence in the event of an investigation being carried out. The home has a care room in which medicine stocks, sundries, aids and equipment are stored. The temperatures of the room and drug fridge are taken and recorded. The drug trolley is kept in a room in another part of the home. However the temperature of this room is not monitored to ensure medicines are stored in accordance with manufacturers’ instructions. Medication administration record charts (MAR) are used to record details of medicines prescribed and administered. However one analgesic was being administered on a “when required” basis which was contrary to the prescriber’s instruction on the MAR chart which indicated it was a regular dose medication. The resident’s latest prescription information sheet did not include this medication. It has not been the home’s practice to record full administration details of “administer when required” medications in the resident’s respective care plan. Neither has it been the home’s practice to use pain assessment charts to monitor the effectiveness of pain treatment plans, where pain is identified as a problem. Some residents are able to self-administer their medications. However in one case there was contradictory information as to who actually was administering a specific medication. Residents said staff treat them with respect when assisting them with personal hygiene needs. Treatments are carried out to residents in the privacy of their own bedrooms. Residents looked well groomed with attention to detail where this is important to them. East Dean Grange DS0000021090.V345614.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Residents who use the service experience good quality outcomes. This judgement has been made using a range of evidence including a site visit to this service. Meals and activities offer both choice and variety. Most residents are supported in attaining their lifestyle preferences. EVIDENCE: Weekly programmes of activities are produced informing residents of the available activities. These include a range of in-house group activities and trips out. Residents are able to join in activities in the neighbouring village hall, attend the adjacent Church or have tea in the nearby tea shop/rooms. Visitors from other churches visit residents who wish to practice their religious observance. Because of the home’s location a twice-weekly taxi trip to Eastbourne is available to residents who like to visit the town. The home’s current brochure includes a reference to bridge being an activity. A resident said they enjoyed playing bridge when living in the community. Sadly bridge is no longer played at the home. Volunteers visit some residents on a regular basis to provide one to one support. The home has an indoor swimming pool, and some residents use this facility, after an assessment and under staff supervision. Visitors were seen coming and going during the visit. Residents said their visitors are always made welcome and offered refreshments. A East Dean Grange DS0000021090.V345614.R01.S.doc Version 5.2 Page 13 selection of newspapers and magazines is available to residents in one of the many sitting rooms. The home has a terrace and well kept gardens for residents to enjoy in the good weather. There is a split-level dining room, with sufficient facilities for all residents to use for their meals if that is their wish. Dining room tables had been nicely laid in preparation of the lunchtime meal and provided a restaurant atmosphere. However some residents prefer to eat in the privacy of their own bedrooms and arrangements are made where this is the case. Menus offer a good selection of appetising meals. Hot drinks and biscuits are available at all times. The home has a new chef and residents spoke positively about the recent changes to their meals. East Dean Grange DS0000021090.V345614.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Residents who use the service experience adequate quality outcomes. This judgement has been made using a range of evidence including a site visit to this service. The home’s current Adult Protection procedure does not sufficiently interlink with the County’s Adult Protection policies and procedures, potentially placing some residents at risk. EVIDENCE: The home ‘s complaint procedure is displayed in the reception room. The home maintains a complaints record book. However a review of this identified that it has not been the home’s practice to include in this book all types of complaints, including niggles. These are usually kept in individual care records. However this system may prevent the home manager and provider getting a clear picture of residents’ opinions of the services currently provided at the home for quality assurance purposes. The review of the file also identified a formal complaint. Some of the content may have constituted adult protection issues. Although the complaint had been investigated under the provider’s complaints procedure there was no recorded evidence the matter had been referred under the County’s Adult Protection (AP) procedures. The home has a copy of the County’s AP procedures. Following a requirement at the last visit, the home has attempted to incorporate details of the local AP procedures into the provider’s AP procedures. However this is still incomplete. The Commission’s InFocus document Better safe than sorry – Improving the system that safeguards East Dean Grange DS0000021090.V345614.R01.S.doc Version 5.2 Page 15 adults living in care homes (November 2006) may prove useful to the home. This is available from the Commission’s website www.csci.org.uk. From information available at the visit it was identified that not all staff have yet received adult protection training. However staff interviewed were able to describe appropriately the action they would take if they had a suspicion of abuse. East Dean Grange DS0000021090.V345614.R01.S.doc Version 5.2 Page 16 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, 21, 22, 25 and 26. Residents who use the service experience good quality outcomes. This judgement has been made using a range of evidence including a site visit to this service. The standard of décor in the home is good providing residents with an attractive and homely place to live. EVIDENCE: Since the last visit the home has had two environmental health inspections. The visits both proved satisfactory. The home is surrounded by well-maintained gardens. Residents said how much they like walking in the gardens, when staff or visitors are available to assist them. The home was clean, tidy and odour free. Bedrooms visited were nicely decorated and had been individualised with personal effects. Rooms vary in shapes and sizes. Some rooms have better outlooks than others. However one resident said they had deliberately picked their room because of the shady East Dean Grange DS0000021090.V345614.R01.S.doc Version 5.2 Page 17 aspect. The home has a variety of sitting rooms for residents to choose where to spend their time. Each bedroom has cable TV, enabling residents to have greater choice of programmes. This is appreciated by one particular resident who commented on the range of programmes they are now enjoying. The property was converted, extended and fitted out some years ago by a previous owner with the original intention of being a private hotel. All bedrooms have en suite bathrooms. However one resident commented on the limitations of the en suite room for their particular needs and preferences. As already stated, the home’s brochure and statement of purpose do not currently provide full details of en suite facilities and the one assisted shower room. It was identified on this visit that handrails are not fitted in corridors. Some residents, unsteady on their feet, were seen walking unaided in these areas. The home has a range of lifting and moving equipment so residents can be safely transferred. For pressure relief/preventative purposes, the home has a limited range of special mattresses and seat cushions, which are used on an assessed needs basis. Residents were very complimentary about the laundry service indicating clothes are generally returned the same day. During the inspection of the laundry some items were seen soaking in an unidentified substance in a bowl standing in the one sink, despite the practice being contrary to the provider’s instructions. The situation impeded ready access to hand washing facilities as it was identified on this visit that there is no separate hand wash sink. The condition of the one and only sink is poor, possibly preventing effective cleaning. The home does not currently have a designated sluicing facility, necessitating staff to empty and clean commode pots in residents’ own en suite rooms. While acknowledging there is only one resident currently affected by this situation, this is poor practice and needs to be properly addressed. East Dean Grange DS0000021090.V345614.R01.S.doc Version 5.2 Page 18 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. Residents who use the service experience good quality outcomes. This judgement has been made using a range of evidence including a site visit to this service. On the whole residents receive care from an enthusiastic, caring and trained workforce. EVIDENCE: In addition to care staff, staff are employed for administration, reception, cooking, activities, cleaning, laundry, maintenance and gardening. Night care cover normally consists of one awake and one asleep carer. The dependencies of residents are monitored and additional awake care staff are rostered where there is an identified need. Currently 75 of permanent care staff are trained to NVQ level II or equivalent. This is good practice. Staff interviewed described their recruitment and appointment experience. This included attending interviews, providing ID evidence, completing forms and being checked against the Criminal Record Bureau database. New staff are required to complete an initial induction programme and undertake mandatory training, including fire and health and safety. This leads into foundation training, in preparation of NVQ training. The induction and foundation training generally follows the Skills for Care guidance. Staff interviewed spoke enthusiastically about their roles and responsibilities. Indeed they were very keen to continue with their development plans in order to obtain better qualifications. The provider facilitates regular training East Dean Grange DS0000021090.V345614.R01.S.doc Version 5.2 Page 19 sessions and recent ones have included safe cleaning, food hygiene, nutrition, infection control, Personal Best, moving and handling and medication administration. A district nurse recently provided training on diabetes. This is good practice as the home has some residents with this condition. However during the visit it was identified that care staff have not received specific training for caring for residents with sight impairments. The home has a resident who is registered partially sighted. A number of staff have received training in preparation of the change over to the new Quest care documentation, which the provider has recently issued to all BUPA care homes. East Dean Grange DS0000021090.V345614.R01.S.doc Version 5.2 Page 20 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, 37 and 38. Residents who use the service experience good quality outcomes. This judgement has been made using a range of evidence including a site visit to this service. The home reviews aspects of its performance through a programme of selfreview and consultations, which include the views of residents and their relatives/advocates. The management of the home is satisfactory overall but records are not well maintained placing some residents potentially at risk. EVIDENCE: The registered manager has been in post for about seven years. Residents spoke positively about the home manager and senior carer. Good interaction was seen between residents, visitors and staff. Residents and staff meetings are regularly facilitated, enabling views and opinions to be discussed. As part of the provider’s quality assurance programme, an annual survey was undertaken in December 2006. The results are included in the information East Dean Grange DS0000021090.V345614.R01.S.doc Version 5.2 Page 21 pack kept in all bedrooms. The provider has updated and provided the care home with new policies and procedures reflecting good practice and current legislation. However a number of out of date policies and procedures were seen displayed in the care room, one of which was dated 1999. The home manages personal monies for a number of residents. Residents’ monies are held in a separate interest bearing account. The system used provides a proper audit trail of how transactions are managed on behalf of residents. The home has a facility to store important items on residents’ behalf. Where this is used, records are maintained. Staff supervision now takes place and staff responsible for this have received training. An incident occurred at the home in February 2007 resulting in a resident being taken to the A & E Department of a nearby hospital. Regulation 37 requires providers notify the Commission of incidents affecting the wellbeing of residents. There is no recorded evidence that the Commission was so informed. While acknowledging that care records are about to be changed, the records in use were not of a standard to provide comprehensive and up to date information to demonstrate all residents’ needs, risks, and preferences had been assessed and recorded. The returned AQAA indicates the home’s equipment is regularly checked, serviced and maintained in accordance with manufacturers’ instructions. In addition to some staff having qualified as First Aiders, other staff have received basic first aid training. Details of accident/incidents are recorded on sheets affixed to a pad. However the current practice of keeping all the completed records together until the pad is finished may jeopardise residents’ confidentiality. East Dean Grange DS0000021090.V345614.R01.S.doc Version 5.2 Page 22 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 3 3 3 3 X X 3 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 2 2 East Dean Grange DS0000021090.V345614.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 Requirement The home’s Statement of Purpose must be reviewed to ensure it provides potential and current residents will more detailed information of the home’s facilities and services. That the adult protection procedure is updated. Timescale 01/12/06 not totally met. All residents must be provided with a care plan setting out full details of the assessed needs, wishes, preferences and choices. All residents must be assessed as to their moving and handling requirements and the information recorded. Medications must be administered as per the prescriber’s instructions. A designated sluicing facility is installed to prevent the current practice of using residents’ own en suite facilities for the emptying and cleaning of commode pots. Care records must be maintained in a way to provide a coherent DS0000021090.V345614.R01.S.doc Timescale for action 31/12/07 2 OP18 13(6) 31/12/07 3 OP7 15(1) 06/08/07 4 OP7 13(5) 06/08/07 5 6 OP9 OP26 13(2) 13(3) 06/08/07 31/03/08 7 OP37 17 31/08/07 East Dean Grange Version 5.2 Page 24 8 OP38 37 picture of residents’ current assessed needs/wishes as well as evidence of care actually being delivered on a daily basis. The Commission must be 24/08/07 informed of all incidents affecting the wellbeing or residents. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 Refer to Standard OP3 OP7 OP8 OP9 OP16 OP18 OP22 Good Practice Recommendations Pre admission information must be appropriately recorded so that information is available to inform the corresponding care plan. This includes re-admissions. Daily records must contain daily entries of the residents’ quality of day, including health and personal care matters. Clinical risk assessments must be used to monitor residents’ assessed needs, including skin integrity, pain and nutrition. Daily temperature checks must be made of rooms used to store medicines to ensure the environment complies with manufacturer’s instructions. It is strongly recommended that details of all complaints and niggles are recorded in a way which provides a quick and effective way of monitoring trends. All care staff should received Adult Protection Training It is strongly recommended that a suitably qualified person including a qualified Occupational Therapist, to advise on the suitability of disability equipment and environmental adaptations, should undertake an assessment of the premises and facilities. It is strongly recommended that hand/grab rails be provided in those areas, which would most benefit residents. It is strongly recommended that to minimise cross infection risks a designated hand wash sink is installed in the laundry; and The deep sink is repaired or replaced. Care staff should receive training to reflect the current assessed needs of residents, including sight impairment. DS0000021090.V345614.R01.S.doc Version 5.2 Page 25 8 9 OP22 OP26 10 OP30 East Dean Grange 11 OP38 Accident books should be maintained in a way to protect residents and staff confidentiality. East Dean Grange DS0000021090.V345614.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 East Dean Grange DS0000021090.V345614.R01.S.doc Version 5.2 Page 27 - 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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