Inspection on 26/03/07 for Fairby Grange Rest Home

This inspection was carried out on 26th March 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Fairby Grange Rest Home 11/10/05

Fairby Grange Rest Home 17/05/05

Fairby Grange Rest Home 25/10/04

Fairby Grange Rest Home 11/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

1 Marten Road

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Fairby Grange Rest Home Ash Road Hartley Dartford Kent DA3 8ER Lead Inspector Justine Williams Key Unannounced Inspection 26th March 2007 09:30 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 Fairby Grange Rest Home DS0000023941.V333880.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. Fairby Grange Rest Home DS0000023941.V333880.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fairby Grange Rest Home Address Ash Road Hartley Dartford Kent DA3 8ER 01474 702223 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) enquiries@fairbygrange.co.uk Mr Gregory Brian Reeve Mr Gregory Brian Reeve Care Home 30 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (1), Old age, of places not falling within any other category (29) Fairby Grange Rest Home DS0000023941.V333880.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Care for one older person with mental health difficulties is restricted to a person whose date of birth is 15 July 1921. 26th May 2006 Date of last inspection Brief Description of the Service: Fairby Grange is a residential care home providing personal care to thirty Older People. Mr G Reeve is the Registered Provider. Mr Reeve is no longer managing the home and the current manager who has worked at the home for 2 years is going through the Commission’s fit persons process in order to be registered. The home employs care staff, working a roster, which gives twenty-four hour cover. The home also employs staff for management, catering and domestic duties. The home is a detached listed Grade II property built around 1685. A purpose built extension was added to the home in 1992. Bedroom accommodation is on two floors and comprises of twenty-four single and three double rooms. Seven single and one double room have en-suite WC facilities. Bedrooms on the first floor are accessed by a chair lift. The home does not have a passenger lift. Three bedrooms on the first floor mezzanine level are accessed by an additional four steps. All bedrooms are connected to the staff call alarm system. Day space comprises of one reception room, a dining room and 2 day rooms, one of which is designated for residents who smoke. The home has well-maintained gardens, including a small, secluded patio area to the rear of the property. The home is located near to the village of Longfield, which has a variety of shops and restaurants, as well as a bank, building society, small library and a church. Train services to London Victoria, the Medway Towns and the Kent Coast are available from Longfield Station. Buses to the neighbouring areas of Dartford, Gravesend and New Ash Green, as well as the Bluewater Shopping complex, pass near the home. Car parking facilities are available. The home is easily accessible by car from the main A2/M25 road junction. The fees payable for Fairby Grange currently range between £360 and £426 per week, this information was given to the inspector at the during the inspection by the manager. Information about the home, including inspection reports by the CSCI, is available from the manager. Fairby Grange Rest Home DS0000023941.V333880.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection was carried out on 26th March 2007 between 09.50 am and 3 pm by regulatory inspector Justine Williams. During that time the inspector spoke with residents individually and in small groups. The manager was on the premises throughout the inspection and feedback was given to the manager during and at the end of the inspection. The Inspector also spoke with the owner and one of the senior care staff, and other staff. This was the first visit to the home by the inspector. All of the key standards and some additional standards were inspected on this occasion. This report contains assessments made from observation, conversation, inspecting records and a tour of the premises. As part of the inspection process comment cards were sent to service users, to GP’s, health care professionals, care managers and relatives of residents. The comment cards received indicate satisfaction with how care managers are kept informed, the staff are receptive to concerns and ideas. Most residents said they always receive the support they need, that staff listen to them, that they sometimes have activities they can take part in and they sometimes liked the meals. Some specific comments from residents were: “I can’t think of anything they could do better really” “The food is okay, I don’t always like the main meal but there is always a choice” “there are not many activities going on, the staff don’t have the time” “I enjoy the trips out but we’ve not been for a while” “the staff are very good, a nice bunch” “they (the staff) do all they can for you” What the service does well: Fairby Grange is welcoming and has a relaxed atmosphere. Residents enjoy living in a clean, pleasant and homely environment. They benefit from the management of the home, which is run in their best interests. Residents receive a comprehensive assessment and benefit from good admission processes, where they are encouraged to spend time at the home Fairby Grange Rest Home DS0000023941.V333880.R01.S.doc Version 5.2 Page 6 meeting staff and having a meal to help them make an informed choice to move in. Lots of work has been done to improve the care plans which now provide a holistic view of the resident and a good level of detail as to how they like and need to be cared for. There are robust recruitment practices in place to ensure residents are protected by the way the home recruits new staff. A good percentage of NVQ qualified staff, available in sufficient numbers, meet residents’ needs. The manager, owner and senior care staff adopt an open and friendly approach, and residents feel able to chat with them about any concerns and worries. What has improved since the last inspection? What they could do better: The fire safety measures must be addressed to ensure the health and safety or residents and staff and visitor to the home, these include conducting regular fire drills in line with fire regulations and providing residents with fire safe door closure devices so that they can have their doors open if they wish. The door opening device required by the fire officer must be fitted to one of the fire escape doors. The fire risk assessment includes all aspect of potential risk and action to be taken to minimise risk. The infection control policy must be reviewed and amended to include cleaning of commodes, hair-washing jugs, use of slings etc. The surface of the bath hoist chair must be made good or replaced The cords around thermometers should be removed or measures taken to reduce risk of infection. Fairby Grange Rest Home DS0000023941.V333880.R01.S.doc Version 5.2 Page 7 The quality assurance systems must be developed further in line with amended regulations, a report must then be produced and should include areas for improvement, to ensure the home is run for the benefit of the residents. The activities must be developed and residents should be able to choose from a programme of activities, which is devised with the residents likes and interests in mind. The care plans must reflect all aspects of need and risk assessments should be expanded upon to detail actions to be taken by staff to minimise risk to residents. A risk assessment specific to falls should be completed for all residents. 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. Fairby Grange Rest Home DS0000023941.V333880.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fairby Grange Rest Home DS0000023941.V333880.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that the home can meet their needs, through good admission procedures. EVIDENCE: All residents now have up to date and comprehensive contracts, which include terms and conditions of residency and all residents have received a copy of the homes statement of purpose and service user guides. Residents have their needs assessed by the manager or one of the senior team leaders prior to moving into the home and are encouraged to visit and spend some time at the home before deciding to move in. The assessment is reasonably detailed and gives a good starting point for staff to enable them to plan the care for the residents. The assessments should be fully completed and not applicable used rather than leaving blank spaces, as this indicates staff have considered all part of the assessment. Resident’s wishes on death and Fairby Grange Rest Home DS0000023941.V333880.R01.S.doc Version 5.2 Page 10 dying should be recorded. Residents are weighed on or shortly after they move in. Intermediate care is not offered at Fairby Grange. Fairby Grange Rest Home DS0000023941.V333880.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are largely met but more thorough recording would better demonstrate this. EVIDENCE: The manager and staff have worked on reviewing all the care plans since the last inspection. The care plans seen were very detailed and set out clearly how the residents needs are to be met. Unfortunately for one newly admitted resident the care plan did not include the plans for how to manage an important aspect of his health and personal care needs, however staff spoken with demonstrated they were providing appropriate care, and liaising with the family and health care professionals involved in order to meet the resident’s needs. Residents spoken with said their needs are met by the staff. The care plans had been regularly reviewed and contained risk assessments, these need to be more detailed as to how risk is to be managed, and the specific actions Fairby Grange Rest Home DS0000023941.V333880.R01.S.doc Version 5.2 Page 12 to be taken by staff. All residents should be risk assessed specifically for falls in line with good practice. Residents good health is promoted by staff ensuring access to health care professionals, residents are weighed on admission and regularly thereafter, residents are not nutritionally assessed using a recognised tool, although the manager spoke about interventions taken by the staff when residents seem underweight or have a poor appetite. Use of a nutrition risk assessment tool will help identify the vulnerable. Residents at risk of pressure sores are referred to the district nurse, and the incidence of pressure sores is recorded and reported to the district nurse. Residents said they can see the GP when they chose and in private. The medication practices of the home have been improved and records were complete. The policy should include the home’s position on residents who wish to self medicate, and how this is to be managed. Homely remedies are included as an appendix to the medicine policy. Controlled medication storage has been addressed with the purchase of an additional cupboard the manager said this meets the requirements of legislation. The manager and team leader said internal and external medicines are now stored separately. Staff have received competency based medication training and training in the Boots monitored dosage system. Residents enjoy good relationships with the staff and said that the staff were friendly and helpful. Staff take care to use the preferred terms of address for the residents. Fairby Grange Rest Home DS0000023941.V333880.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ quality of life could be improved by regular and planned suitable activities. Residents benefit from contact with their relatives and friends if they wish. EVIDENCE: Residents spoken with said that there were not many activities going on, though some said they preferred not to participate in activities. The home does not have a schedule of activities for residents and there are no designated staff running activities. The manager said that she is looking into having someone come in regularly to run activities and produce a plan. Outings and trips are arranged occasionally though the manager said these had not happened recently, the manager is aware of the need to review the provision of activities. Residents said they enjoyed playing cards but had not played in a while. The manager now asks for residents likes and dislikes and hobbies and interests on admission and care plans also include social activity, this information should be used when devising a plan of activities. Fairby Grange Rest Home DS0000023941.V333880.R01.S.doc Version 5.2 Page 14 Residents are encouraged to keep contact with their relatives and friends if they wish and staff spoken with confirmed this. One resident celebrated her 90th birthday over the previous weekend, and the home hosted the party provided party food, etc, which was enjoyed by the residents. Residents felt they could make choices and have control over their lives, from times of getting up and going to bed to contributing to the residents meetings many spoken with felt they could chat to the manager about the home. Residents had mixed impressions of the standards of food, all agreeing that the food was well cooked, although some said there were lots of ready meals meaning food prepared elsewhere such as the Cornish pasties which were the alternative on the day of inspection with spaghetti bolognese. Residents are able to eat their meals in the lounge or their own rooms if they prefer though most chose the dining room. The cook works until 2pm and suppers are prepared by care staff that have a valid food hygiene certificate. Special diets are catered for and there are plans to end the cook on course recommended by the environmental health officer. Fairby Grange Rest Home DS0000023941.V333880.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected from abuse and there is a complaints policy in place. EVIDENCE: There is a complaints policy in place, and the home has not received any complaints, a suggestion book has also been started and this is available in the entrance hall. Unfortunately the residents and other visitors to the home have not made any entries yet, but the manager said she would welcome any feedback. Residents said they had no complaints and if they were unhappy would either speak with the manager or team leader. The adult protection policy needs amendment to remove any reference to staff investigating as this is the job of social services or the police. Staff receive information at induction about adult protection but no other training, though staff spoken with demonstrated a reasonable understanding of adult protection Fairby Grange Rest Home DS0000023941.V333880.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): 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a pleasant environment. Safety of residents could be improved by ensuring full compliance with new fire safety guidance and legislation and reviewing some of the infection control procedures. EVIDENCE: Residents continue to describe the home as a very pleasant environment to live in and those spoken with liked their rooms and the communal areas. The grounds were well maintained and all areas of the home pleasantly decorated. There is a reception room, a dining room and two lounges, one of which is designated for residents who smoke. Residents’ accommodation consists of twenty-four single rooms, seven of which have en-suite facilities, and three shared rooms, one of which has en-suite facilities. This is arranged over two floors. Residents’ rooms are personalised and homely. They are able to bring furniture from their own home if they wish. Fairby Grange Rest Home DS0000023941.V333880.R01.S.doc Version 5.2 Page 17 Residents who wish to have their doors open must be able to do so safely with a fire compliant device. The fire risk assessment is very brief and does not include all aspects of potential fire hazards. Staff must do regular fire drills in line with new fire safety legislation. The recommendation from the last fire safety inspection to fit a door opening device to the door leading to a fire escape has not yet been carried out. The water temperature was 48°C in 2 bathrooms, instead of the recommended 43°C, the owner who does the maintenance said he would put this right immediately. The home was clean and tidy and pleasant smelling the infection control policy must be developed to include cleaning of commodes, the bath hoists, and single use of slings. The use of jugs for hair-washing must be reviewed or strict guidance for cleaning between residents must be put in place. The surface of the bath hoist seat has been damaged and may present an infection control hazard, this must be made good or replaced. Fabric cords around the thermometers should be removed to reduce the risk of cross infection. Fairby Grange Rest Home DS0000023941.V333880.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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by the skill mix, qualifications and numbers of staff. Residents are protected by the home’s robust recruitment procedures. EVIDENCE: Residents said they did not have to wait long for assistance and the numbers of staff are appropriate to meet the needs of the current service users. The home is usually run on 3 care staff in the morning, 3 in the afternoon and 2 at night, in addition the manager is there from 8.30 to 4.30 Monday to Friday. 1 of the care staff on duty in the morning is allocated to helping in the kitchen and doing laundry duties and is therefore not available to help with personal care. Care staff prepare the evening meal, in addition to their caring duties. Domestic staff work in the morning only so any cleaning needed in the afternoon is the job of care staff. In addition to their caring duties night staff peel vegetables and do ironing. Care staff also run activities as there are no designated activity staff. These arrangements should be reviewed regularly to ensure the care of residents is not compromised by care staff performing other duties. More than 50 of staff have attained NVQ qualifications, some of them have NVQ 3. Fairby Grange Rest Home DS0000023941.V333880.R01.S.doc Version 5.2 Page 19 The manager has employed 1 new member of staff since the last inspection and their file was seen. The file contained 2 written references, CRB and POVA check, proof of identity, etc the recruitment policy is clearly being worked to, although some minor amendments are needed to ensure it complies with the changes in the regulations. The manager was required to improve staff training at the last inspection and it was clear that lots of work has been done to ensure all staff have had core training and additional training in specialist areas to enable them to do their jobs. The manager is now preparing a matrix to keep track of training completed and training due. All staff receive induction which they must have signed off by a senior member of staff. Fairby Grange Rest Home DS0000023941.V333880.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): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the residents however, the health safety and welfare of residents will be better protected when the fire safety and other minor healthy and safety issues are addressed. EVIDENCE: The manager of the home is going through the fit persons process with the Commission now, and has recently completed the Registered Managers Award. The manager has been registered at another home as manager previously and has several years experience in managing care homes. The manager has undertaken several training courses recently to update her knowledge and skills. The manager is supported in her role by the 2 senior carers. Fairby Grange Rest Home DS0000023941.V333880.R01.S.doc Version 5.2 Page 21 The home has regular residents meetings to discuss various aspects of the running of the home and to allow residents to be involved with the running of the home, the home also sends out questionnaires to get the views of residents and relatives. The quality assurance systems must be further developed in line with new regulations and a copy of the report produced sent to the Commission. The Manager has carried out supervision of the staff but said many staff are now overdue their next session. The home holds small amounts of cash on behalf of some residents. Transaction records and receipts are kept, all residents able to do so are asked to sign their records. The manager ensures safe working practices with regard to moving and handling, first aid, food hygiene, thorough training of staff, many staff have recently begun an infection control course and as mentioned previously in the report some of the practices and the policy need review. The Skandia frames in the toilets should be fixed to the floor to prevent toppling or alternative equipment fitted, to ensure residents safety when using the toilets. Staff have received fire safety training but the risk assessment, timing of the drills, recommendations from the last fire inspection, and door opening devices need review. The home ensures regular portable appliance testing, servicing and maintenance of equipment is carried out. The manager is aware of her responsibilities to report incidents and accidents etc. Fairby Grange Rest Home DS0000023941.V333880.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 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 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 2 X 2 X 3 X X 2 Fairby Grange Rest Home DS0000023941.V333880.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? 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 OP12 Regulation 16 (n) Requirement The registered person must consult service users about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including, having regard to the needs of service users, activities in relation to recreation, fitness and training. The registered person shall establish and maintain a system for reviewing and improving the quality of care and supply the Commission with a report in respect of the review. The registered person shall ensure the home is conducted so as to promote and make proper provision for the health and welfare of service users in that; • • • Fairby Grange Rest Home Timescale for action 30/05/07 2 OP33 24 30/09/07 3 OP38 12 (1)(a) 30/05/07 Fire drills are conducted regularly in line with fire regulations The fire safe door opening devices are installed where required. Automatic door closure Version 5.2 Page 24 DS0000023941.V333880.R01.S.doc • • • • device is fitted to the door leading to the fire escape. The fire risk assessment includes all aspect of potential risk and action to be taken to minimise risk. The infection control policy is reviewed and amended to include cleaning of commodes, hair-washing jugs, use of slings etc. The surface of the bath hoist chair is made good or replaced The cords around thermometers are removed or measures taken to reduce risk of infection. 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 OP7 OP7 Good Practice Recommendations Care plans must be reflective of residents’ current condition. Risk assessment specific to falls should be completed for all residents. Fairby Grange Rest Home DS0000023941.V333880.R01.S.doc Version 5.2 Page 25 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 Fairby Grange Rest Home DS0000023941.V333880.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!