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Inspection on 14/09/06 for East Dean Grange

Also see our care home review for East Dean Grange for more information

This inspection was carried out on 14th September 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The findings from this inspection and the feedback from a range of sources, form the view that East Dean Grange provides a high standard of care to the people who live there. East Dean Grange provides hotel style accommodation, with the addition of dignified support where necessary. As such, residents are able to be as independent or as supported as they choose.The service is provided within an attractive setting, giving each resident the option of spending time in well maintained and decorated private or communal areas. East Dean Grange gives residents the opportunity to participate in a range of fulfilling social activities, both inside and outside the home. Residents benefit from the supported and safe use of the on site, heated swimming pool. Mealtimes are arranged as either social or private occasions, where visitors can be included. Lunchtime meals are served with starter, main course, dessert and followed by coffee. All residents spoken with during the inspection, commented positively about the service they receive.

What has improved since the last inspection?

East Dean Grange continues to provide a high quality of care and has worked at improving the care documentation ensuring its accuracy and regular review. The management have also arranged for staff who provide staff supervision to have relevant training and the supervision sessions have been reviewed and adapted.

What the care home could do better:

Not all residents admitted to the home have a full needs assessments completed prior to their admission. These need to be completed by a competent person to ensure any resident admitted to the home can have all their needs met. Staff must be provided with clear guidelines to be followed following an allegation or suspicion of abuse is made and staff need to receive appropriate associated training to ensure residents are protected from any form of abuse. The homes recruitment practice was found to be lacking and did not follow robust recruitment procedures to ensure residents are protected.

CARE HOMES FOR OLDER PEOPLE East Dean Grange Lower Street East Dean East Sussex BN20 0DE Lead Inspector Melanie Freeman Key Unannounced Inspection 10:00 14 September 2006 th 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.V305919.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.V305919.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 www.bupa.co.uk BUPA Care Homes (CFCHomes) 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.V305919.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 1st December 2005 Date of last inspection Brief Description of the Service: Care First Care Homes Ltd, a subsidiary of BUPA homes owns East Dean Grange. It is registered to provide care for 33 older people. The home offers hotel style accommodation in a large detached country house situated in the village of East Dean approximately 4 miles from Eastbourne. The home has an indoor swimming pool on site, a drinks bar and designated parking areas in the extensive and well-maintained grounds. The home has a shaft lift and chair lift that provide access to most areas except for three rooms in the older part of the building. All bedrooms are en-suite and decorated to a high standard. In addition to the en-suite facilities there is a communal shower and the baths have an electric seat to improve access. The dining area is on two levels and there are additional lounge areas. Included in the fees is a taxi service to Eastbourne twice a week. The home is close to the church, village hall and public house. Residents are able to participate in local events and groups should they wish to. The home has dedicated activity organisers. The home provides care and support to residents who are privately funded. The home’s fees are from 01 July 2006 and range between £539.00-£848.00 per person per week depending on the room to be occupied. Additional costs are charged for chiropody (approx £12) hairdressing (approx £10-40), newspapers and magazines. The homes literature states that the Philosophy of the home is simple and believes that each individual should be treated as a unique independent person with a right to privacy and freedom of choice. East Dean Grange DS0000021090.V305919.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at East Dean Grange will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and a further visit, which was completed via an appointment to meet individually with three carers and to spend some further time with the resident. Following the visits to the home contact was made with resident’s representatives and a visiting health care professional. The inspection visits were facilitated by the senior carer, who was in charge of the home in the registered managers absence, she received the direct feedback from the inspector at the end of the visits. The inspector was able to spend time with residents and their visitors and observe care practice in the home. A tour of the premises was undertaken and a range of documentation was reviewed including the homes statement of purpose and service users guide, care plans, duty rotas, medication records, and recruitment files. The care documentation pertaining to three residents was reviewed in depth along with a number of policies and procedures and records relating to health and safety. The inspector was able to eat a midday meal with a resident in the communal dining room during the unannounced visit. In addition service users surveys were given to 10 residents or their representatives and 5 staff surveys were left in the home for staff to complete and return. The inspector received 8 service users/representatives surveys and one staff survey was returned, information contained in the returned surveys has been incorporated into this report. What the service does well: The findings from this inspection and the feedback from a range of sources, form the view that East Dean Grange provides a high standard of care to the people who live there. East Dean Grange provides hotel style accommodation, with the addition of dignified support where necessary. As such, residents are able to be as independent or as supported as they choose. East Dean Grange DS0000021090.V305919.R01.S.doc Version 5.2 Page 6 The service is provided within an attractive setting, giving each resident the option of spending time in well maintained and decorated private or communal areas. East Dean Grange gives residents the opportunity to participate in a range of fulfilling social activities, both inside and outside the home. Residents benefit from the supported and safe use of the on site, heated swimming pool. Mealtimes are arranged as either social or private occasions, where visitors can be included. Lunchtime meals are served with starter, main course, dessert and followed by coffee. All residents spoken with during the inspection, commented positively about the service they receive. 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. East Dean Grange DS0000021090.V305919.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.V305919.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): 1, 3, and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from the provision of comprehensive and well-presented documentation, which enables them to make an informed choice about whether to move into East Dean Grange. Not all residents have had a needs assessment completed prior to admission. EVIDENCE: The home provides a combined statement of purpose and service user guide and a copy of this document was available at the front entrance area along with the most recent inspection report. On admission, each resident is given a welcome pack, which incorporates all required information. The pack is well-presented and provides accessible information about the home and the terms and conditions attached to a stay at East Dean Grange. East Dean Grange DS0000021090.V305919.R01.S.doc Version 5.2 Page 9 The certificate of registration is displayed in an appropriate area and is correct. When reviewing the quality of the pre admission needs assessments it was identified that the last two admissions to the home had not had a needs assessment completed prior to admission. This shortfall was discussed with the senior carer and the importance of this as part of the admission process. A review of the homes admission procedure confirmed that these assessments are to be completed by the home wherever possible and other arrangements are to be used when this is not possible. Residents and relatives who discussed the admission process said that they had chosen East Dean Grange over other homes and people who had experience of the home had recommended it. Intermediate or rehabilitative care is not provided at East Dean Grange Care Home. East Dean Grange DS0000021090.V305919.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): 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. Residents benefit from a person centred approach to care, which provides them with the support needed in a dignified and respectful manner. Procedures and practice in the home allow for the safe administration of medicines. EVIDENCE: The care documentation pertaining to three residents was reviewed as part of the inspection process and each of these residents were met with during the inspection visit to the home. The plans of care were found to be individualised and to promote resident’s independence and the use of risk assessments were well developed. The documentation demonstrated the regular review of individual risk and the care provided. It was however noted that some care documentation is completed to a higher standard than others. This was discussed with the senior carer for further review. East Dean Grange DS0000021090.V305919.R01.S.doc Version 5.2 Page 11 Staff spoken to clearly had a good understanding of residents care and social care needs and demonstrated how they promoted residents independence through good communication. Treating residents with dignity and respect is clearly a priority and the rapport seen between staff and residents was very good and a key worker system is well established. All feedback received from residents and relatives was all very positive about the standard of care provided at the home saying ‘I am delighted with the home they have met my aunts needs in a thoughtful way’, ‘the home is first class and totally suitable for my mother it provides hotel services’, ‘the home balance the promotion of independence and dignity with the care needs’. Medicines are stored in the office area and a medicine trolley is used when administering medicines. The senior carer confirmed that only senior staff who had received relevant training were permitted to administer medication. There was evidence that the systems in place ensured medication was managed in an individually focussed way and enabled those residents who want to administer their own medicines are able to do this. East Dean Grange DS0000021090.V305919.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): 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. Residents benefit from the opportunities to lead sociable and fulfilling lives with the activities and entertainment provision in the home being well managed and ensuring a varied provision. The meals provided are varied and well presented however some improvements are needed to ensure they meet resident’s expectations. Residents are able to make a range of choices about their lives as well as maintaining links with friends and relatives. EVIDENCE: East Dean Grange has dedicated activity co-ordinators who provide organised activities five days each week. All activities are well promoted with an emphasis on residents leading what they wish to do. During the inspection it was noted that many of the residents were sitting or walking in the garden, some were reading and mixing with each other or with staff. One resident said how much she enjoyed the swimming pool that she used regularly. East Dean Grange DS0000021090.V305919.R01.S.doc Version 5.2 Page 13 One resident said ‘Vicky is splendid at arranging activities and the staff are good at arranging quizzes which are interesting and beneficial for failing memories’. The inspector observed that residents were given choices at every opportunity and that these are well respected. Residents are encouraged to keep links with the community and the home joins in the community events held within East Dean village. Visiting is greatly encouraged and one regular visitor said that she really enjoyed visiting her mother and described it as a ‘gentile place to have tea’. Visitors are welcome to join their relative or friend for a meal at a reasonable fee. Residents confirmed that they can choose where to take their meals and where they have visitors, a separate table is laid to enable them to share the meal together. The dining rooms are very attractive and allow residents to have their own dining table where they can have all their meals if they wish. The care staff serves the individual meals directly from the kitchen ensuring the meals are well presented and served at the correct temperature. The facilities and presentation is one of a good quality hotel. Surveys received and discussions with residents during the inspection visits along with the experience of eating a meal with one of the residents confirmed that although the food was satisfactory and choices are given, the food was not as good as it has been in the past. On the day of inspection two residents commented on the gammon being tough and the soup being salty. The management of the home are aware that there have been some problems and is working with the catering manager to improve the provision to the high standard expected. East Dean Grange DS0000021090.V305919.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): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Procedures and practices in the home ensure that complaints made are managed appropriately, with residents and representatives being confident that they are listened to and responded to. The home’s procedures and staff training do not ensure that the correct alerting procedures are followed once an allegation or suspicion of abuse is highlighted. EVIDENCE: The home has a detailed and clear complaints procedure in place. It gives clear guidance with regard to how a complaint can be made and how the complainant can expect it to be dealt with. The complaints procedure is available in the homes brochure and feedback received from residents and relatives confirmed that they felt confident that if they raised a concern this would be listened to and responded to appropriately by the home manager or the senior carer. The complaint records seen were comprehensive and confirmed that all complaints are taken seriously and responded to effectively. A review of the home adult protection procedure available on the first site visit was not reflective of the local guidelines and did not provide the correct guidance for staff to follow when an allegation or suspicion of abuse is raised. Since this visit the senior carer has been reviewing the homes procedure and updating the guidance in the home. Staff spoken to had not received training on adult protection issues. East Dean Grange DS0000021090.V305919.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): 19, 20, 21, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in an attractive home with a safe environment that is well maintained and clean. East Dean Grange promotes individualised rooms with suitable facilities to meet resident’s needs. EVIDENCE: East Dean Grange is a converted premise that has been extended and adapted to its present use and offers a very attractive environment with character. The home has a programme of routine maintenance and its own maintenance. The grounds of the home are safe, tidy and accessible and provide a very pleasant area. During the inspection visits residents were walking and sitting in the garden and said to the inspector how much they liked the gardens. There are three areas of communal space- a main lounge with a small bar, a music room and a sun lounge. The home also has an attractive restaurant that is on two levels. All offer a high standard of accommodation. East Dean Grange DS0000021090.V305919.R01.S.doc Version 5.2 Page 16 Residents have attractive bedrooms and are able to personalise them with furniture and their own possessions. All bedrooms have en-suites that include a bathing facility that can be adapted with bath seats and shower attachments. Discussions with staff and residents clarified that despite some mobility problems all residents are able to use the current bathing facilities in the home and are able to move around the whole home safely. The home was found to have a high standard of cleanliness throughout. Some residents use commodes at night and the commode pots are cleaned in the ensuite rooms the promotion of good infection control practice was discussed with the senior carer to follow up. East Dean Grange DS0000021090.V305919.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): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing numbers and skill mix provides a competent staff team that can meet residents health and personal care needs. The recruitment practice was found to be poor as it did not ensure all the necessary checks are completed before an individual starts working in the home. EVIDENCE: At the time of this inspection 27 residents were living at East Dean Grange and the staffing arrangements were found to be appropriate to meet the care needs of the residents. A staff rota was available for inspection. This showed that four carers are on duty in the morning with a senior carer or manager also working in the home. There are in addition sufficient catering and cleaning staff. On the whole residents and staff said that there are sufficient staff on duty to meet the needs of residents although one resident felt there had been some staff shortages/ changes and staff felt the mornings could be very busy. The senior carer assured the inspector that suitable staffing levels are maintained at all times with the use of bank staff or agency staff if required. The management prefer not to use agency staff, as they are not familiar with the home or the residents. East Dean Grange DS0000021090.V305919.R01.S.doc Version 5.2 Page 18 Staff interviewed spoke positively of the team spirit and the standard of care that they can provide at East Dean Grange, it was apparent that there is a stable core group of staff at the home that enjoy their work but expressed dissatisfaction with their wages. Residents and relatives were very complimentary about all the staff working in the home saying ‘the staff are helpful welcoming and accommodating and the staff are not patronising’, ‘the staff are very patient and kind’, ‘the staff are very nice’. The recruitment files pertaining to the three most recently employed carers were reviewed as part of the inspection process and identified that one carer was working without a POVA and CRB check being completed by the home another carer did not have all the required identity records. An immediate feedback form was left in the home with the senior carer to require that the home do not have people working in the home without the necessary checks being completed. The inspector confirmed at her follow up visit that a POVA first check had been completed and that this carer was working under supervision. The pre-inspection questionnaire completed by the registered manager confirmed that 75 of care staff have now completed the required National Vocational Qualification at level 2 or above in care. Staff training is well developed and new documentation to cover the new induction standards has been developed. A training matrix is used to record and plan all staff training. East Dean Grange DS0000021090.V305919.R01.S.doc Version 5.2 Page 19 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): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and ensures the best interests of residents are protected. Quality assurance measures allow for residents and representatives views to be taken in to account and responded to. Systems are in place to ensure resident’s monies are safe and health and safety issues are well managed. East Dean Grange DS0000021090.V305919.R01.S.doc Version 5.2 Page 20 EVIDENCE: The registered manager has been in post at East Dean Grange for the past six years and has an experienced manager with relevant qualifications. He is well supported by a dedicated team of senior staff who ensure that individual care and support needs are met. Both residents and staff spoke positively about the management of the home and said that both the manager and senior carer were very approachable and responsive to any comments. Residents and visitors questionnaires are completed on an annual basis these are audited by head office with a report going to the home manager. The last report was very positive and was completed in Autumn 2005 with the reports being provided to residents and other interested parties, although the manager responds to the audit report this is not recorded. Staff views are not included in this quality report and this was discussed during the inspection to ensure staff feel that their views are taken in to account. There are strict procedures in place regarding the documentation of ‘pocket money’ and receipts are required for every transaction and records seen at the time of this visit were accurate and up to date. Those residents who use the ‘pocket money’ system in the home receive individual monthly statements. All relatives spoken to said that they were aware of all the costs and were happy with the arrangements. All records relating to health and safety matters were found to be full and thorough. The home has also been subject to an Environmental Health Officer inspection earlier in the year and this found that the home had Health and Safety policy and procedures in place along with appropriate risk assessments. East Dean Grange DS0000021090.V305919.R01.S.doc Version 5.2 Page 21 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 X 1 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 2 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 East Dean Grange DS0000021090.V305919.R01.S.doc Version 5.2 Page 22 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 OP3 Regulation 14 Requirement Timescale for action 01/10/06 2. 3. OP18 OP29 13(6) 19(1) That no resident moves into the home without having their needs fully assessed by a competent person. That the adult protection 01/12/06 procedure is updated and further staff training is provided. That the registered person 01/10/06 ensures a thorough recruitment procedure is operated that includes the appropriate checks being completed before any person is deployed to work in the home and includes the retention of the required records in the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP15 Good Practice Recommendations That the catering provision is reviewed with a view to improve the quality of this facility. DS0000021090.V305919.R01.S.doc Version 5.2 Page 23 East Dean Grange 2. OP22 3. 4. OP26 OP33 That an assessment of the premises and facilities should be undertaken by a suitably qualified person including a qualified Occupational Therapist, to advise on the suitability of disability equipment and environmental adaptations. That the practice of emptying and cleaning commode pots in the en-suite facilities is reviewed to ensure best infection control practice is followed. That a report is made on how the QA audit report is used and responded to and that staff surveys are used to inform the home’s quality review. East Dean Grange DS0000021090.V305919.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. Extracts may not be used or reproduced without the express permission of CSCI East Dean Grange DS0000021090.V305919.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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