CARE HOMES FOR OLDER PEOPLE
Farway Grange 31-33 Howard Road Queens Park Bournemouth Dorset BH8 9EA Lead Inspector
Jo Pasker Unannounced Inspection 30th April 2008 12:15 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 Farway Grange DS0000020462.V362414.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. Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Farway Grange Address 31-33 Howard Road Queens Park Bournemouth Dorset BH8 9EA 01202 511399 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) farwaygrange@hotmail.co.uk Mr S Nathoo Mrs Freda Isabel Bonard Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26), Physical disability (8), Physical disability of places over 65 years of age (26) Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 2nd July 2007 Brief Description of the Service: Farway Grange is registered as a care home providing nursing and personal care for up to twenty-six older people and also can accommodate a maximum of eight younger adults within the twenty-six places. The home is situated in the residential area of Queens Park within a short distance of the shopping centre, the seaside and other local amenities. There are bus routes nearby into Bournemouth centre, where there are good local and national transport links. Farway Grange consists of two converted older type houses numbers 31 and 33 Howard Road. Number 31 has two floors and number 33 has three floors. The two houses are linked at ground level. A passenger lift services number 33 and a stair lift reaches the four bedrooms on the first floor of number 31. There are twenty-three bedrooms in total providing twenty-six places. The communal space consists of a lounge situated on the ground floor of number 33 and a large well maintained garden. Car parking is available to the front of the home or in the surrounding roads. Mr Nathoo, who is the Registered Provider, owns the home and is in the process of submitting an application for the registration of a manager, who deals with the daily running of the home. The fee prices in May 2008, range from £550-£900 per week for nursing care. The manager said that rates are negotiable and dependent on individual needs. The fee does not include hairdressing, chiropody, aromatherapy and transport. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at www.oft.gov.uk and the following website offers further guidance on fees and contracts: http:/www.csci.org.uk/about_csci/press_releases/better_advice_for_people_c hoos.aspx The home holds a copy of the most recent inspection report, which is available, on request. Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 5 Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes.
This unannounced key inspection was carried out over approximately 6 hours on the 30 April and 6 May 2008. This was a statutory inspection and requirements and recommendations made as a result of the last inspection visit were also reviewed. The manager was on hand throughout to aid the inspection process and the Registered Provider, Mr Nathoo, also was present for the second day of the inspection. Information gathered for this report came from several sources including: • Reports made to the Commission for Social Care Inspection by the home. • The annual quality assurance assessment (AQAA) completed by the home. • 6 questionnaires completed by residents, relatives and visitors. • Tour of the premises. • Review of a variety of documentation including care records, staff records, maintenance records, policies and procedures. • Discussion with residents and staff. During the course of the inspection 8 residents, 5 visitors and 7 members of staff were spoken with and asked their views on the service provided at the home. Comments received through the questionnaires and discussion included: • • • • ‘There’s a lovely atmosphere here’ ‘I’m very happy with the care, although they can be busy at times’ ‘I like the food’ ‘The staff are very friendly’. What the service does well:
All the residents, visitors and staff spoken with reflected that the home was a friendly place and the management very approachable. The home continues to ensure that a thorough assessment of needs is carried out prior to residents moving into the home and people are assured that their needs will be met.
Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 7 The home consults residents and their representatives about care plans and these reflect specific nursing needs, such as diabetes and catheter management. The general health needs of residents are well met with several different external healthcare professionals involved in delivering care. Activities and links with the local community are good and the home continues to have a varied calendar of events organised throughout the year. The home has a welcoming and warm atmosphere and visitors are actively encouraged to participate in the home’s events. Residents are offered a good variety of meals and individual choices and requirements are well met. The home has an effective complaints policy and procedure in place, which ensures that residents’ and relatives’ concerns are well managed. The house and garden are maintained to provide residents with a comfortable place to live. Residents are encouraged to personalise their rooms with items of furniture, pictures and a variety of mementos. Staff are well trained and considerate and caring, with a good knowledge of residents’ needs. The home manages its quality assurance system well and provides resident centred care. Financial procedures within the home also ensure that residents’ interests are protected. Health and safety is promoted and expected requirements are met ensuring that peoples’ safety is maintained. What has improved since the last inspection?
Care plans now contain more detailed information so that staff are aware of the actions needed to ensure that the health, personal and social care needs of residents are fully met. Fluid balance charts are also now kept as needed. Clear audit trails were seen for medication held and amounts corresponded to documentation held; all opened packets of medication were dated and the main medication publication used, was seen to be in date. Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 8 The home have made available patient information leaflets for all medicines administered within the home, to provide residents and their relatives with details of the effects of the medications they are prescribed. The list of abbreviated signatures of nurses involved in medicine handling was seen to be complete (i.e. includes all nurses engaged in this work in the home, including agency staff). The home now offers sufficient recreational activities to the residents at weekends, including an activity organiser who also works some Saturdays. The home now uses a heated food trolley at mealtimes, which ensures that meals are served at the optimum temperature and individual portion sizes can be provided. Staff have had training in adult protection to ensure that all are adequately trained to prevent residents being harmed or being placed at risk of harm or abuse. The laundry floor and walls appeared to be kept clean to minimise the risks to infection control or fire safety. Qualified nurse staffing levels are continuously reviewed to ensure that at all times there are sufficient nurses to meet the complex nursing needs of residents’ accommodated. 50 of care staff have the NVQ level 2 award in care or equivalent and more staff are starting their level 3. The home’s manager is now completely supernumerary, ensuring that management practice and procedures are given the dedicated time needed to ensure that the home is run in the best interests of residents. The home has now started to produce a newsletter for the benefit of residents, visitors and staff. Financial procedures within the home ensure that residents’ interests are protected. Appropriate blood lancing devices (as recommended by the pharmacy inspector) are now used for blood glucose level checks. Records of care were seen to be kept up to date with relevant information. Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 9 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. Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 10 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 Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 11 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): 3 (Standard 6 is not applicable to this service). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admissions procedure enables prospective residents (and/or those acting on their behalf), to make informed decisions about admission to the home and ensures that only residents whose needs can be met by the home are offered places there. EVIDENCE: The pre admission documentation for 1 resident was inspected. This showed that the home has a good procedure in place and ensures that a full assessment of needs was undertaken with the prospective resident, family and hospital staff prior to them moving into the home. Sufficient information was obtained so that a comprehensive care plan could be drawn up for staff to follow and ensure that individual needs are met. Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 12 Some visitors were spoken with who were visiting the home in preparation for their mother to be admitted the following day. They were seen getting the bedroom ready with personal effects, supported by the home, to make their mother feel more welcome on her arrival. They confirmed that they had visited the home before and were given sufficient information about Farway Grange before making a decision. They stated that they had chosen the home, as it appeared ‘clean, friendly and smells nice’. The resident was spoken with on the second day of inspection and stated that she was ‘very happy to be here….much better than hospital’ and also was pleased with the meal choices and seeing her family most days. Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 13 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. Detailed care plans are now available for individual residents and accurately reflect the practice that is carried out, in meeting people’s needs and preferences. The health needs of the residents are well met with evidence of good support from community health professionals and residents are treated with dignity ensuring that that their rights and privacy are upheld. Improvements have been made to standards for medicine handling and recording to safeguard residents from risk, however some minor shortfalls still exist. EVIDENCE: Since the last inspection there has been a gradual transition to a different style of care planning documentation however, improvements were seen and all the
Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 14 relevant paperwork was available. The care files for 4 residents were reviewed and contained a variety of assessments. The information from the assessments was used to formulate a plan of care for each resident and they contained sufficient detail so that staff could give the appropriate care. There was evidence that some care plans had been discussed with the resident or their representative as the relevant person had signed them or it had been documented if a resident had refused to sign them and why. Residents appeared well cared for and people spoken with confirmed this. ‘The staff are very nice’; ‘I don’t need for anything’. They also confirmed that staff treated them with respect. It was clear from discussions with staff, residents and family members that there is access to the health services needed. There was evidence to show that residents get support from General Practitioners, the district nurse, chiropodist, dietician and specialist nurses. Appropriate referrals are also made to physiotherapy services when needed. The medications policies and procedures were reviewed and these have improved since the last inspection, which was carried out by a pharmacy inspector on 9 October 2007. Medicines were stored securely, clear audit trails were available for medicines received, held and disposed of and medicine information leaflets, relevant to each resident, were kept in their files. Some minor recording shortfalls were seen though: • • Not all residents had allergies or ‘none known’ listed The recording of the disposal of a deceased residents medication was misleading, as it indicated that it had not been kept for 7 days (as required), although this procedure had actually been followed. A list of designated and appropriately trained staff to handle medication was seen and up to date medication information books (such as the BNF) were also available. Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. The home provides a wide range of activities and events for residents and they are encouraged to maintain contact with the local community. Friends and relatives are also warmly welcomed by the home. Both relatives and staff members assist residents to make choices, enabling them to achieve control over their lives and the meals offered provide choice and variety ensuring that residents receive a wholesome diet. EVIDENCE: The home employs 2 activity organisers who arrange a variety of activities based on the needs and preferences of the residents. One of the organisers sometimes works on a Saturday and there are always games available for any staff member to play with residents at the weekends. Residents who are either unable to participate or choose not to participate in group activities, are visited individually. On the first day of inspection one person had gone swimming accompanied by an activity organiser and on the second visit to the home, several people had gone on a trip to Salisbury for the day. Farway Grange has a range of different vehicles that enable residents to go out and about, individually or together as a group.
Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 16 Some people attend day centres, a supported nursery project or visit Farway Grange’s sister home, the Alexandra Centre, up the road. Residents are able to attend church services if they wish and visiting clergy are made welcome. The manager stated that she had arranged to meet a new clergy person to look at taking multi denominational services within the home. Residents and visitors spoken with confirmed that visitors are made welcome at any time and that they are able to spend time privately in residents’ rooms if wished. One visitor said they were very happy with the home and ‘They’re lovely here’. All rooms seen contained personal pictures, photographs, ornaments and some items of furniture. Farway Grange positively encourages families and friends to come in and make a person’s room as individual as possible, to meet that resident’s needs and preferences. They have also redecorated some rooms when needed, in the preferred style of a resident. Residents were seen to be enjoying the lunchtime meal and staff seen to be giving appropriate assistance to those who needed it and required more time to eat. The home employs 2 chefs, who will speak to each person in the morning about their daily preferences and there is a menu file in each room. Cooked breakfast is available and there was fresh fruit in the lounge. The home now owns a hot trolley for food, which is taken to the lounge at mealtimes, ensuring that individual portions can be served at the optimum temperature for residents. The Environmental Health Department (EHO) last visited in December 2007 and all actions required were taken by the home, ensuring that the kitchen met acceptable EHO standards in January 2008. Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 17 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. The home has a good complaints system, which ensures that complaints are managed properly and residents and relatives can be sure that their concerns will be listened to and acted upon. Policies and practice, in order to safeguard residents from potential abuse and harm, are also promoted. EVIDENCE: No complaints had been received since the last inspection. Residents and visitors spoken with said that they knew how to complain and felt confident that if they had concerns or complaints they will be listened to and taken seriously. The home has policies and procedures for the protection of residents from abuse or neglect and provides all staff with training in the understanding of abuse and their role in protecting residents from abuse in its many forms, including neglect. Staff spoken with confirmed that they had received training and demonstrated a clear understanding of the home’s procedures. The details of 3 adult protection safeguarding referrals have been given to CSCI-2 were found unsubstantiated by the Commission and 1 has had no further action taken. The local social services are the lead investigators for all safeguarding referrals and responsible for the final overall outcomes.
Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 18 Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 19 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, 25 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment at Farway Grange is good providing residents with an attractive, homely and safe place to live. EVIDENCE: The home employs a dedicated maintenance person and has a programme of on going routine maintenance. The bathrooms have recently been refurbished to a high standard though some of the cloakrooms were seen to be quite dated, however, the Registered Provider, Mr Nathoo, was well aware of this and plans to gradually refurbish these areas. The majority of rooms now have ceiling hoists and records show the equipment and facilities within the home are regularly serviced. Since the last inspection several areas in the home have been upgraded, including: • The fitting of a stair lift to building 31
DS0000020462.V362414.R01.S.doc Version 5.2 Page 20 Farway Grange • • • • A new office area New hall, lounge and stair carpets New kitchen flooring New office and kitchen equipment A covered smoking area has also been introduced outside as well as a vegetable area in the garden, for use by residents who enjoy gardening. Not all radiators are covered, to lessen the risks of accidental burns, however the home have carried out thorough individual risk assessments for all residents and heated surface areas and taken appropriate measures where necessary. On the first day of inspection, the downstairs sluice smelt very offensivehowever, by the second visit this had been rectified by the home and all areas smelt very clean. A full time housekeeper is also employed, ensuring that all areas are kept very clean and tidy. The laundry continues to be well managed within the home, with all residents’ clothing labelled and named individual boxes used for washing. The floor and walls of the laundry room appeared clean, following a requirement made at the last inspection. Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 21 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. Sufficient care staff are employed and receive the training and support needed, so that they can give a good standard of care to the residents living at Farway Grange. Good recruitment procedures are in place to protect residents from the risk of unsuitable staff working at the home, however best practice is not always implemented. EVIDENCE: Staff rotas demonstrated that there were sufficient staff on duty to meet the needs of the residents and this was observed in practice, during the inspection. The management system has changed since the last inspection, with a supernumerary manager now in place and enough care staff on duty to provide the necessary care and attention to residents. Visitors and residents commented that staff were always available and although they ‘are very busy’ no one has to ‘wait long for someone to come and help’. The home has an ongoing training programme, which includes NVQ level 2 and 3 in care and at the time of inspection more than 50 of the care staff hold the minimum of a level 2 award in care. A further 3 members of staff were working towards their level 3 award.
Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 22 Three staff recruitment files were reviewed. All files contained the information and documents required, including POVA first and enhanced Criminal Record Bureau checks. However, 1 reference had been crossed through by the referee and another written by a member of staff working at Farway Grange. It was discussed that this was not acceptable and that more detail or another reference would be required. Training files demonstrated that staff were receiving induction training and the home have recently allocated a joint induction/NVQ trainer position to a member of staff at the Alexandra Centre. The Registered Provider has also appointed a moving and handling trainer to cover both homes, ensuring continuity of training and skills. The majority of staff have received all mandatory training required, including infection control, moving and handling and fire training. However, some staff still needed to attend training in these areas and the home have further sessions planned. Further information on available training can be accessed through the following websites: www.picbdp.co.uk www.skillsforcare.org.uk Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 23 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 good. This judgement has been made using available evidence including a visit to this service. The home is well organised, with good quality assurance systems being developed and the daily management and running of the home centres around the best interests of the residents and their finances. The welfare of all people is well promoted and protected, ensuring that risks to health and safety are minimised. EVIDENCE: At the time of inspection there was not a registered manager of the home, however, Mr Nathoo, the Registered Provider had appointed Ms Sue Wilgress, part time, to manage the home on a day-to-day level. Ms Wilgress was suitably experienced and qualified to manage the home and had made significant improvements since taking up her post, which included improved
Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 24 care documentation; recruitment and training of staff and quality assurance. It was discussed with Mr Nathoo; the importance of having a full time dedicated registered manager in post and meeting the required management arrangements legally. He has since informed the Commission that he will be putting forward a suitable full time candidate for the post of registered manager, whilst Ms Wilgress continues to manage the home in the short term. The home has submitted an annual quality assurance assessment (AQAA) to the Commission, detailing how they currently meet Care Standards and how they plan to improve. Updated annual questionnaires for residents, families and other stakeholders have been implemented to gain their opinions on the running of the home. There is an annual development plan in place and the home plan to implement the use of more clinical audit tools. The home has also started to produce a newsletter, Farway Times, which is made up of contributions from residents, their families and staff. Residents either deal with their own finances or have a representative to do so. The home will hold a small amount of money for people, which is administered by one member of staff. Records and amounts sampled evidenced that this was well managed. Health and safety appeared well managed within the home. Records showed that staff had received recent training in fire safety and manual handling updates; equipment had been serviced regularly; hazardous substances, such as cleaning fluids, were seen to be stored securely and accidents were recorded and appropriate action taken as necessary. Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 25 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 26 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 OP29 Regulation 19 Schedule 2 Requirement The registered provider must ensure that, prior to a member of staff commencing employment all the information outlined in Schedule 2 of the Care Homes Regulations 2001 is obtained. • Two valid, independent written references must be obtained for all newly employed staff prior to starting work and any omissions or concerns verbally followed up and documented. Timescale for action 31/07/08 A requirement regarding references was also made in the last report 02/07/2007. 2 OP31 8(1)(a) & 9 A person is not fit to manage a care home unlesshe/she has the qualifications, skills and experience necessary for managing the care home. • The Registered Provider must put forward a suitable candidate for the Registered Managers position. • The Registered Manager
DS0000020462.V362414.R01.S.doc 30/11/08 Farway Grange Version 5.2 Page 27 must demonstrate that they possess, or are working towards, a management qualification, which is equivalent to the Registered Manager’s Award. This requirement has been repeated from the last report 02/07/2007. 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 OP9 OP33 Good Practice Recommendations Recording relating to medication handling and storage should accurately reflect practices within the home. Various monitoring audits should be implemented within the home to further improve the quality assurance process. Farway Grange DS0000020462.V362414.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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
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