Inspection on 03/04/07 for Grace Lodge

This inspection was carried out on 3rd April 2007.

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.

Other inspections for this house

Grace Lodge 06/10/05

Grace Lodge 22/12/04

Grace Lodge 05/10/04

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

CARE HOMES FOR OLDER PEOPLE Grace Lodge Grace Lodge 4 Manor Road South Hinchley Wood Esher Surrey KT10 0QL Lead Inspector Suzanne Magnier Unannounced Inspection 3rd April 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 Grace Lodge DS0000013654.V333247.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. Grace Lodge DS0000013654.V333247.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grace Lodge Address Grace Lodge 4 Manor Road South Hinchley Wood Esher Surrey KT10 0QL 020 8398 0580 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) thakur@gracelodge.freeserve.co.uk Mr Vikram Thakur Mrs Lopa Thakur Care Home 15 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (15), of places Sensory Impairment over 65 years of age (1) Grace Lodge DS0000013654.V333247.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th October 2005 Brief Description of the Service: Grace Lodge is a detached property, located approximately two miles from Esher town centre. The property provides two sitting rooms, conservatory and dining room. The home has a mature garden, which surrounds the rear of the house. The home has eleven single bedrooms and two shared bedrooms. Nine of the bedrooms have en-suite toilets. A lift facility is provided to enable service users to gain access to the first floor bedrooms and bathroom. The home has ample car parking space. The fees for this service range from£500.00 to £540.00 per week. Grace Lodge DS0000013654.V333247.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five and a half hours starting at 09.30 and finishing at 14.45 and was the first key inspection to be undertaken in the Commission for Social Care Inspection year April 2006 to 2007. Ms S Magnier Regulation Inspector carried out the inspection and the registered manager represented the service. For the purpose of the report the manager advised that people living in the home prefer to be referred to as residents. A tour of the premises took place and the inspector met with the majority of the residents. The home provides care and accommodation to fifteen residents and employs 15 staff (inclusive of housekeeping and bank care staff). Comments from residents, their relatives and friends and other health care professionals have been included in the report. Records sampled included care plans, risk assessments, menus, health and safety records, and some policies and procedures. The home had sent a variety of cards and letters to the commission, which had been received by the home, to express thanks and gratitude for the care, kindness and support the management and staff had given to residents during their stay at the home. The inspector would like to thank the residents, staff and managers for their time, assistance and hospitality during this inspection. What the service does well: All residents spoken with during the course of the inspection spoke highly of the staff and the service/care received at the home. The manager advised that the home had recently received the Gold Food Hygiene Award demonstrating the attainment of high standards in all areas of food control and also received the Young at Heart Awards which is awarded to caterers for the provision of healthier food choices for older people, provision of non-smoking areas and good standards of food hygiene. Visitors are welcomed to the home to maintain contact with their family members. Comments from relatives and visitors included ‘ There is always a welcoming cup of tea, the home is very clean and comfortable, and the staff very friendly and helpful. Overall we are satisfied with everything’. ‘The care of my mother has been fantastic. I cannot believe any other home would have given her as much kindness and affection’. ‘On the whole I am very happy Grace Lodge DS0000013654.V333247.R01.S.doc Version 5.2 Page 6 with the level of care Mum is receiving and she is happy which is the most important thing’. ‘My relative has been much healthier and happier since being a resident’. ‘The home allows residents to live their own lives within the home but also tries to involve them in entertainments and events. I always feel they have time for all the residents.’ One General Practitioners comments included ‘ Grace Lodge is an excellent residential home and I am proud to be associated with it’. From the evidence seen by the inspector and comments received, the inspector considers that the home provides a service to meet the diverse needs of individuals of various religions and their racial or cultural needs. Comment from relatives regarding diversity included ‘They encourage mum to practice her faith of Christianity in the home and encourage the pastor of her church to visit and bring Communion’. The home has a ‘big multi cultural ethos’. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Grace Lodge DS0000013654.V333247.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 Grace Lodge DS0000013654.V333247.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides well-written documentation and visits to the home for prospective residents in order that they can make an informed choice about moving to the home. The homes admission and assessment procedures ensure that resident’s needs are appropriately identified and met. Terms and conditions/contracts of stay are available to residents. EVIDENCE: The care plans sampled by the inspector evidenced sound pre admission assessments of resident’s needs including abilities, preferences mobility, health care needs, dietary needs, social needs, a photograph of the resident, any known allergies and current medication. Each care plan contained the terms and conditions of residency, which had been signed by the resident and documentation to support that the home Grace Lodge DS0000013654.V333247.R01.S.doc Version 5.2 Page 9 offers trial periods of stay and opportunities to visit the home prior to residency. The inspector noted that the updated Statement of Purpose, aims and objectives, the last Commission for Social Care report (CSCI) report and also the visiting arrangements of the home are on display in the home and available to residents and visitors. No intermediate care is offered by the home. One resident who had recently moved to the home told the inspector that they felt settled and liked the home. A comment card received as part of the homes Quality Assurance stated that the residents felt they were given enough information and staff helped them to ‘unpack and have a nice cup of tea, I was treated well and listened to right from the start’. Grace Lodge DS0000013654.V333247.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The resident’s individual plans of care are comprehensive and demonstrate that their health and personal care needs are met. There was clear demonstration that medication was administered to all residents in a safe and appropriate way. EVIDENCE: The care plans sampled had been developed from appropriate pre assessment documentation regarding the care needs and support of the resident and reviewed regularly to reflect any changes in the residents needs. Where possible, and depending on the service users choice, it was noted that family members had input regarding their relatives care plans. The care plans included documented risk assessments for all areas of the resident’s life in order to promote independence whilst ensuring the residents safety and well-being. Grace Lodge DS0000013654.V333247.R01.S.doc Version 5.2 Page 11 During the inspection the inspector met with a relative in the home who said that they come to the house unannounced to visit their relative and on every occasion their relative is settled and well cared for at the home by the staff. The relative was visiting from overseas to support their relative to a hospital appointment and one staff member was also available to offer transport. Relative’s comments stated they are ‘immediately informed of important issues and not hassled with unimportant/administrative issues’ ‘The home allows me to feel that my mother is well cared for and is in capable hands so that some responsibility is taken from me’. ‘My mother has been at Grace Lodge for 3 years and I would not like to see her moved’. ‘I feel they are looked after extremely well and all their needs are taken care of’. The inspector was advised by the manager that the home continues to maintain strong professional links with the local hospice and seeks support and training when necessary to promote the service users dignity, respect and care. The care plans evidenced that regular and appropriate health care appointments are attended and the General Practitioners (GP) visit the home. G.P. comments included ‘The home has particularly good liaison with district nurses and will also follow up tests and ensure that out patients appointments are logged.’ ‘ The home provides excellent physical care in a pleasant family – like social environment.’ It was evident that the home has maintained good working partnerships with health care professional which include visits from the district nurse, opticians, dentists, chiropodists, physiotherapists, occupational therapists and community psychiatric support when required. Comments from healthcare professionals included ‘A great deal of attention is paid to the health care needs of individuals’. ‘There have been times when staff have been required to look after patients whose needs had become more those appropriate to a nursing home. However this does not necessarily imply a deficiency –they have coped very well without full nursing experience and have not always been helpfully supported by Social Services’. The home ‘involves all residents in day-to-day activities, chats, games, conversations, family stories. A warm atmosphere is created and residents feel involved and cared for’. ‘The manager has sought advice appropriately re patients in my care and acted upon advice given- good open communicative relationship.’ Residents weight is monitored by the home and records have been kept. Daily notes are clearly documented to describe what care and support given to residents. Grace Lodge DS0000013654.V333247.R01.S.doc Version 5.2 Page 12 Throughout the inspection the inspector observed that residents were addressed in a polite and courteous way by staff. Some residents told the inspector that the staff ‘this is like home from home’ ‘they look after us very well’. Whilst sampling the care plans the inspector observed that there was written evidence to support that the residents were offered respect of their privacy and dignity through the home offering gender specific care and being sensitive to residents choices. The inspector observed that the home has a monitoring dosage system in place, which is maintained to ensure the safe handling of medicines in the home. All medication administration charts were well documented with no gaps or errors noted. The manager explained that the local dispensing pharmacist chemist had undertaken a recent audit and the GP surgery work well with the home to ensure that medication needs of the residents are met at all times. The home has a medication policy and procedure and all medication was observed as stored and checked, including controlled drugs. Healthcare professionals comments regarding the homes procedures for medication included ‘ the resident I have been involved with does not administer their own medication but is offered medicines appropriately and encouraged to request analgesia, aperients as needed. This is the area in which I have been most closely involved in offering advice to both residents and staff’. Grace Lodge DS0000013654.V333247.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 good. This judgement has been made using available evidence including a visit to this service. A variety of activities take place both inside and outside of the home. Visitors are welcomed to the home to maintain contact with their family members. Resident exercise control and choice over their lives. The food at the home was of a good standard. Crockery and equipment available to residents promoted their independence and choice. EVIDENCE: The atmosphere of the home was peaceful and calm. Several residents were seen to be reading the daily newspaper, having a visit from the hairdresser and moving freely around the home. One resident was observed to be watering the plants and had a chat with the inspector whilst another was doing their knitting. The home offers a wide assortment of books from the homes library and also a talking book for residents with sensory impairments. One resident told the inspector that they like to feed the birds in the garden and this gave them a sense of great enjoyment. Another resident told the inspector that it was nice not to have the television on all the time. One resident advised that they attend a blind club and also meet with church friends each week. The manager explained that the staff are committed to ensuring that residents have a variety of stimulating activities both inside and Grace Lodge DS0000013654.V333247.R01.S.doc Version 5.2 Page 14 outside of the home. These activities include a Pat dog, music for health, Bingo, gardening, manicures and shopping in the main town or local shop. The home provides escorted transport for residents to take part in activities in the community. The home has arrangements for residents to receive spiritual support and Holy Communion in the home at the resident’s request. Comments from relatives included ‘Great family atmosphere, always something going on’. Always kept informed and the information helps me to make decisions,’ Mum has had a couple of falls recently and the care home have phoned us up immediately’. A health care professional comments included ‘I have observed residents being encouraged but never forced to be included in group activities, one resident often reads in their room late at night and is not discouraged from this. Visitors appear to be free to come and go as residents choose and go out with family members who I believe are invited to lunch with the resident at the home also.’ The management and general hygiene in the kitchen was good. The menu was sampled by the inspector and clearly evidenced that wholesome and varied meals are provided for residents. The inspector sampled that there was a choice of meals served during the lunchtime, with one resident clearly enjoying a curry. Individual staff were noted to be available to residents who needed additional support which was given in a dignified manner. Crockery, cutlery and equipment to assist residents to maintain independence were available. The meals served were hot and well presented. One relative told the inspector that the food in the home was very good and special diets, including cultural meals suitable to the needs of their relative were provided. The dining area in the home was noted as spacious and the manager explained that the home experiment by using different dining room furniture to assist residents for example the home have adapted dining room chairs in order that residents can slide the chair more easily under the table when they have finished their meals. As part of good practice the manager advised that the Surrey Primary Care Trust dietician had recently visited the home and would be offering training to support staff in providing an assessment tool in order to ensure that residents nutritional needs are maintained. The manager advised that the home had recently received the Gold Food Hygiene Award demonstrating the attainment of high standards in all areas of food control and also received the Young at Heart Awards which is awarded to caterers for the provision of healthier food choices for older people, provision of non-smoking areas and good standards of food hygiene. Grace Lodge DS0000013654.V333247.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. The residents are protected by the homes complaints and safeguarding adults procedures. EVIDENCE: The home has recently updated the complaints procedure. The manager advised that no complaints had been received by the home. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. Several residents told the inspector that they were confident that the manager or staff would deal with any concerns or complaints they may have. Records sampled indicated that staff had attended safeguarding vulnerable adults training and for newly recruited staff this had been included in the induction programme. No safeguarding referrals have been made. Comments received from relatives included ‘Mum has always been happy since she has been there and I certainly have never heard her complain about her care’. ‘All suggestions are promptly taken up’, ‘I would see the care manager in the first instance with any complaints but I would not be sure how to take things further’, We have never had any cause to raise concerns’. Grace Lodge DS0000013654.V333247.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 good. This judgement has been made using available evidence including a visit to this service. The home has a clean and hygienic environment and is of sound construction. EVIDENCE: The homes environment is comfortable and homely and continues to meet the needs of the residents. A comment from a relative included ‘I feel the décor of the Care Home could be smartened up a little bit and be made a little more comfortable’. The inspector sampled a maintenance log, which the home had developed to ensure that ongoing repairs in the home were undertaken. Specific areas where some decoration and repairs were necessary for example the replacement of the carpet leading into the dining room and some decorative repair in the sluice area were identified within the maintenance log. The manager explained that the home had recently employed a maintenance Grace Lodge DS0000013654.V333247.R01.S.doc Version 5.2 Page 17 person who would be undertaking the repairs and decoration within the home following receipt of further employment checks. During the course of the inspection a replacement side bath panel was fitted as the existing panel was cracked. It was noted that to the left of the pathway beside the external laundry there was a drop that did not have a rail fitted and could potentially be a hazard to residents in the area. It has been recommended that a barrier is erected to ensure that residents do not fall or trip over the edge of the pathway. The home was noted to be clean and hygienic throughout. Grace Lodge DS0000013654.V333247.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. The staffing levels of the home were evidenced as adequate to meet the current needs of residents. The residents were fully protected by the homes recruitment policy and procedures. Staff are trained and competent to do their jobs. EVIDENCE: The home had a relaxed atmosphere and staff were observed to undertake their tasks in a quiet and orderly manner. The inspector met with several residents all of whom spoke favourably about the staff, comments included ‘they are angels, the care and attention received is always excellent’. Comments received from relatives included the staff are ‘always supportive and kind and seem competent in their jobs’, ‘The care home always looks after Mum very well and nothing is too much trouble. They do their job very well’.’ I am very impressed with the home and find the carers so helpful.’ The staffing levels of the home were evidenced as adequate to meet the current needs of the residents. The home employs a number of staff from overseas that has National Vocational Qualification (NVQ) equivalence, as they are qualified nurses in their country of origin. Six of the nine staff have NVQ level 2 or above. Grace Lodge DS0000013654.V333247.R01.S.doc Version 5.2 Page 19 The manager demonstrated that she recognised the diverse needs of the staff group regarding their training needs. During the inspection the manager attended an appointment with the Surrey Care Association regarding the ongoing staff-training programme. Records indicated that the training programme offered mandatory and specialised training for example management of continence, oral health and palliative care. Records evidenced that the home had several staff that were recently employed and records indicated that the Common Induction Standards and mandatory training programme was in place for the staff. The manager demonstrated an awareness and commitment to staff training and ongoing support. The recruitment files sampled were generally in good order. A shortfall in the recruitment process was identified whilst sampling two staff files of people newly recruited, with regard to references. It was noted that one staff file contained a reference ‘to whom it may concern’ and another file lacked any references as the manager explained that staff member had not previously been employed. In discussion with the manager it was identified that references could be obtained and these were confirmed as sought immediately following the inspection in order to ensure that the residents were protected by the homes recruitment and selection policies. One health care professional commented ‘ I have been pleasantly taken with the responsive nature of all contact with staff at the home’ Grace Lodge DS0000013654.V333247.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 excellent. This judgement has been made using available evidence including a visit to this service. The management of the home is robust to ensure the safety and wellbeing of residents. Residents are consulted regarding the running of the home and their health and financial interests are safeguarded. EVIDENCE: The manager explained that she has a clear role in the home and oversees the care of residents and staff whilst the director is responsible for the administrative work. Grace Lodge DS0000013654.V333247.R01.S.doc Version 5.2 Page 21 All persons spoken with during the inspection spoke highly of the abilities and knowlegde of the manager and staff morale was good. Written comments from relatives and visitors to the home included ‘There is always a welcoming cup of tea, everyone is very polite and friendly’, ‘Help is always at hand and the care is excellent’.’ Your staff and you are all wonderful’, ‘Very caring management and staff’. ‘I suppose there is always room for improvement but nothing springs to mind’. ‘I feel that the carers show genuine concern for the welfare of each of the residents. The home is also very welcoming to visitors’. ‘My sister has been in Grace Lodge for one year and she feels she is at home. The staff are all very efficient and caring and the home is always kept at a very high standard.’ It was noted that the manager had a good rapport and knowledge of each of the residents. It was observed that the manager and staff listen to the resident’s views and opinions and opportunities to share ideas are held. The pre inspection documentation advises that the home does not involve themselves in the financial affairs of the residents and alternative arrangements are made through the families or Power of Attorneys. The Director of the home has access to residents personal finances records of which were not sampled during the inspection. Records indicated that health and safety checks are maintained, fire safety equipment and records were documented and equipment serviced. The sluice and laundry areas were noted to be clean and tidy. Clinical waste was appropriately stored to reduce infection in the home and hand-washing facilities were available for staff. Special arrangements have been made for the collection of clinical waste. Grace Lodge DS0000013654.V333247.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 3 3 3 X 3 3 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Grace Lodge DS0000013654.V333247.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action 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 OP19 Good Practice Recommendations It has been recommended that a barrier is erected to ensure that residents do not fall or trip over the edge of the pathway by the side of the external laundry. Grace Lodge DS0000013654.V333247.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Burgner House 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 Grace Lodge DS0000013654.V333247.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. 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!