Inspection on 03/04/07 for Grace Manor Care Centre

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 Manor Care Centre 23/10/06

Grace Manor Care Centre 25/10/05

Grace Manor Care Centre 06/12/04

Grace Manor Care Centre 14/06/04

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

CARE HOMES FOR OLDER PEOPLE Grace Manor Nursing Home 348 Grange Road Gillingham Kent ME7 2UD Lead Inspector Sue McGrath Key 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 Manor Nursing Home DS0000026175.V335370.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 Manor Nursing Home DS0000026175.V335370.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grace Manor Nursing Home Address 348 Grange Road Gillingham Kent ME7 2UD 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) 01634 570230 01634 580469 Grace Manor Care Limited Mrs Karen Ditch Care Home 60 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Grace Manor Nursing Home DS0000026175.V335370.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To admit service users who require nursing care from the age of 55 years. The maximum number of service users to be accommodated is 60. Date of last inspection 23rd October 2006 Brief Description of the Service: Grace Manor is a Nursing Home for Older People. The home caters for 60 people with various nursing needs. The main part of the home was an old Manor House and the décor etc. is in keeping with the period of the home. The new addition affords service users en-suite rooms and there is plenty of day space to choose from. There is a courtyard garden at the centre of the home, which is a suntrap in the summer, which service users enjoy and benefit from. The home itself is set in generally well-maintained grounds and overlooks the river Medway. The nearest town is Gillingham, which has a main line railway station and high street stores. There is some parking to the front of the building. The home has recently been granted registration for a 12 bedded Dementia Unit The fees are from £496.00 to £785.00 per week. Grace Manor Nursing Home DS0000026175.V335370.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a random inspection following a poor key unannounced inspection that took place last year. Many improvements were noted this time and the inspection was made a key inspection to ensure the rating could be amended. Sue McGrath, Regulation Inspector for the Commission for Social Care Inspection, conducted both inspections. The random and key inspections for care home services are part of the new methodology for The Commission For Social Care Inspection. The actual date of the site visit is unannounced. At the site visit, service users and staff were spoken to, records were viewed and a tour of the environment was undertaken. Some judgements have been made through observation only. The requirements made at the last inspection had been complied with. What the service does well: What has improved since the last inspection? Since the last inspection several areas of improvement have been completed with regards to the environment and these include sixteen redecorated bedrooms, nine with new carpets. All of the redecorated rooms have new curtains, bedcovers and cushions. The lounge and dining room have also been redecorated. The kitchen has had some improvements made to the fixtures and fittings and some new equipment has been purchased. The manager now monitors the kitchen on a regular basis. Grace Manor Nursing Home DS0000026175.V335370.R01.S.doc Version 5.2 Page 6 Staff records have improved. Training has been improved and the home will meet the required 50 of staff with a minimum of NVQ level two when all courses have been completed in June. Mandatory training and induction training has also improved. The maintenance of equipment used within the home has improved and records are now in place to evidence this. 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 Manor Nursing Home DS0000026175.V335370.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 Manor Nursing Home DS0000026175.V335370.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes Statement of Purpose and Service User Guide are comprehensive and provide prospective residents with the information they need to make an informed choice about moving into the home. Residents are protected by a contract that reflects their terms and conditions and right and responsibilities. EVIDENCE: As required from the last inspection the home’s statement of purpose and service users guide have been separated and updated and now contain all of the relevant information required by regulation. Copies of these documents are in all of the bedrooms. The manager stated that these were now more readily available for all residents and prospective residents. Grace Manor Nursing Home DS0000026175.V335370.R01.S.doc Version 5.2 Page 9 Evidence was seen in residents’ files that the home conducts extensive preadmission assessments to ensure they can meet the new residents needs. The manager stated that they try not to accept emergency admissions if possible. Families confirmed that they have been involved in the admission process. Evidence was also seen that residents are issued with legal contracts and terms and condition, which give details of terms and conditions and rights and responsibilities. Following the last inspection the homes has now applied for twelve beds to be used as dementia care beds. These will be contained in a dedicated unit. The home is currently training staff and endeavouring to appoint a senior nurse/manager to manage the unit. It is advised that no further residents, with a diagnosis of dementia, are admitted until staff are fully trained and the senior staff member is appointed. The manager confirmed that all residents are offered a trial period of normally four weeks to ensure they are happy to remain and that the home can meet their needs. Visiting family members confirmed this is normal practise. The home does not offer intermediate care. Grace Manor Nursing Home DS0000026175.V335370.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have care plans that identify their individual needs and give clear guidance to staff. Care plans are regularly updated to ensure both physical and emotional health needs are met. Changes are recorded and acted upon. Health needs are met and residents have full access to all professional health care services as required. Residents are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Senior staff now regularly reviews care plans and staff benefit from a daily handover period. All residents now have nutritional risk assessments in place. Work continues to ensure residents are involved in the reviews and in the drawing up of these plans. The manager has tried hard to obtain information from families regarding resident’s wishes regarding terminal care and Grace Manor Nursing Home DS0000026175.V335370.R01.S.doc Version 5.2 Page 11 arrangements after death, but has found the information difficult to obtain from some relatives. However, this had been handled in a sensitive way and the home will continue to try and obtain this information as soon as possible. Work continues on improvements to the care plans. All of the residents are registered with a local GP and have full access to specialist medical, nursing, dental and chiropody services as needed. Evidence was also seen that the home manages tissue viability well and has a named specialist viability nurse in the home. Medication was reviewed and the records evidenced that the home follows the Royal Pharmaceutical Guidelines. As recommended in the last report the medication policy has been updated to reflect actual practise. The registered manager now regularly audits the medication procedure and some nursing staff have completed a Safe Administration of Medication course. The manager confirmed that all nurses would eventually complete the course. No errors were found in the signing of the MAR sheets. The home may need to replace the controlled drugs cupboard in the near future, as it is fairly small. During the course of the inspection staff were seen to be respectful of the residents and used appropriate terms of address. Grace Manor Nursing Home DS0000026175.V335370.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. Service users’ social and recreational interest and needs are well provided for with a wide range of activities organised. EVIDENCE: The home has one activities co-ordinator who works Tuesdays to Fridays and offers a full programme of activities within those times for the nursing side. The manager is currently employing another activity co-ordinator who will work mainly with the residents with dementia, when the new wing is fully operational. Current activities include bingo, musical movement, indoor bowling, quizzes, armchair exercises, giant hangman, a video club, musical karaoke, a library round and ball exercises. Organised social activities recorded include belly dancers, professional entertainers, a bonfire night party with a barbeque, a halloween party, a summer fete and a strawberry cream tea event. Various other social evenings are arranged, with families being invited to attend all these activities. Grace Manor Nursing Home DS0000026175.V335370.R01.S.doc Version 5.2 Page 13 Local schools attend at Christmas time to sing carols and a local minister visit every two weeks. The activities co-ordinator will also assist residents with their private mail if they wish. Residents are encouraged to exercise choice and control over their lives where possible but staff are willing to assist if necessary. Residents confirmed they can bring in personal items on admission and the manager confirms this is encouraged within the boundaries of health and safety requirements. The majority of the residents said the food was nice and that they have a choice. The manager confirms that where possible fresh produce is always used. Three full meals are available every day with drinks readily available. Evidence was seen that the residents are offered a full choice at every meal. Specialist diets can be provided when advised by health care professionals. Staff were seen to assist those residents who require feeding in a caring and sensitive manner. Grace Manor Nursing Home DS0000026175.V335370.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 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 clear and effective complaints system in place. Residents are protected by robust adult protection policies and procedures and staff have received training in Adult Abuse. EVIDENCE: The home has a written complaints procedure, which is contained in the service user guide and is available in the foyer and in the resident’s rooms. At the last inspection the majority of families spoken with did say that if they had any complaints they would not hesitate to talk to the manager. The home has not received any formal complaints since the last inspection. The home has received many compliments from families regarding the level of care offered to their loved ones. The home had adopted the Kent and Medway Adult Protection Policy and Procedures. The majority of the staff have now completed, or are about to complete, training in Adult Protection as required from the last inspection. Grace Manor Nursing Home DS0000026175.V335370.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a mainly clean environment and have safe access to comfortable indoor and outdoor communal areas. EVIDENCE: A general tour of the building was undertaken and some of the bedrooms were viewed. The home generally was found to be clean and tidy. Some odours were again noted in the main foyer and in some of the bedrooms but the staff were working diligently to address these issues, as at the previous inspection. Since the last inspection several areas of improvement have been completed and these include sixteen redecorated bedrooms, nine with new carpets. All of the redecorated rooms have new curtains, bedcovers and cushions. The lounge and dining room have also been redecorated. The kitchen, which was a major problem at the last inspection, has improved although it has not been fully refurbished. Two new sets of stainless steel Grace Manor Nursing Home DS0000026175.V335370.R01.S.doc Version 5.2 Page 16 drawers units have been fitted along with new flooring. The larder has been painted and new shelves have been fitted. The badly frosted freezer was now clear from frosting and one new fridge has been purchased. One new food mixer and a new thermometer probe have also been purchased. Staff now appear to be more vigilant over kitchen cleanliness and the manager regularly monitors the condition of the kitchen and the cleaning schedules. Following a request from CSCI the Environmental Health Office visited the home. It now has a positive report from the Environmental Health Officer. As reported in the last report the outside of the home is starting to look in need of redecoration, particularly the poor state of the window frames. The main driveway remains in need of repair. Grace Manor Nursing Home DS0000026175.V335370.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ care, social and emotional needs are promoted by the employment of care staff in sufficient numbers. Residents benefit from staff that are now trained and competent to do their jobs and who enjoy good morale. EVIDENCE: The ratios of care staff to service users is determined according to the assessed needs of residents, and a system operated for calculating staff numbers required, in accordance with guidance recommended by the Department of Health. From discussions with the manager, observations by the inspector and reviewing the staff rotas, sufficient staff were on duty at the time of inspection to meet the resident’s needs. The home employs 12 ancillary staff who work as cleaners, laundry cooks, gardener and maintenance staff. The home is currently looking to recruit more domestic staff. This allows care staff the time to meet the needs of service users. Grace Manor Nursing Home DS0000026175.V335370.R01.S.doc Version 5.2 Page 18 The manager confirmed that on three days a week three nurses are employed at all times but on four days a week only two nurses are employed, however it is noted that beds numbers are currently low, with only 39 beds occupied. The manager agreed that when full (60 beds) the home must have a minimum of three nurses at all times. The home now has a training matrix in place, however this does not show dates of when training is undertaken. This was discussed with the manager who agreed that if the dates were added it would make the planning of future training session easier. The home has made a great effort to ensure staff now have the basic mandatory training in place and the levels of National Vocational Qualifications has improved. The home now has twelve care staff with level two and two staff with level three. Fifteen other staff are working towards their level two qualifications and four are working towards level three. This is out of thirty-five care staff. Three other members are hoping to start their awards in the very near future. When staff have completed their awards the home will exceed the required 50 of staff with NVQ to a minimum of level two. This is a good improvement from the last inspection. Twenty-six staff have completed Adult Protection training and the remaining staff will complete the course before June 07. Twenty-four staff have completed Fire Awareness training and another session is booked for June 10th 2007. Seven staff have completed a one day First Aid course. Eleven staff have completed a one day training course in dementia and a further eleven are completing a distance learning dementia course which should be completed within the next three months. One member of staff has completed a distance learning course in Infection Control and four more are undertaking the course. The home has clearly invested a lot of time and money in staff training as required from the last inspection report. The home’s induction programme for new staff does now meets with the guidance from the National Training Organisation (NTO) workforce training targets and ensures staff fulfill the aims of the home and meet the changing needs of residents. This was a requirement from the last inspection. All members of staff receive induction training to NTO specification within 6 weeks of appointment to their posts, and foundation training within 6 months. Grace Manor Nursing Home DS0000026175.V335370.R01.S.doc Version 5.2 Page 19 The home shows that it undertakes a recruitment practice including submission of an application form detailing all previous work history, requests proof of I.D and copies of qualification certificates, seeks two written references, confirms work status and also undertakes some telephone checks. The home’s recruitment files were seen and confirmed this was happening; again this was an improvement from the last inspection. Grace Manor Nursing Home DS0000026175.V335370.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a service which is safe and well managed. Sound financial procedures protect residents. Current arrangements were sufficient to protect the health, safety and welfare of residents and staff. EVIDENCE: Since the last inspection the manager has completed her registration with the Commission and is now the Registered Manager. Throughout the inspection the manager was open and honest and assisted in the inspection. It was evident that since the last inspection a considerable amount of work had been undertaken and the inspection generally was more positive. Grace Manor Nursing Home DS0000026175.V335370.R01.S.doc Version 5.2 Page 21 Staff confirmed that the manager is approachable and communicated a clear sense of direction and leadership. Quality assurance was again discussed and although the home does undertake some quality assurance by means of asking residents to complete questionnaires, they do need to expand on this to ensure full compliance with Standard 33. The Registered Manager has started to look at this standard and does intend to fully meet the requirements by the next inspection. The manager is strongly advised to fully familiarise herself with this standard and to implement quality assurance and quality monitoring system based on seeking the views of service users, families and of stakeholders in the community such as doctors, care managers and other professionals. This will enable the organisation to ensure it is meeting the goals they set out in their own Statement of Purpose. The organisation needs to develop a written business and financial plan for the establishment, which can then be open to inspection and be reviewed annually. Residents’ families are encouraged to handle the monies of residents who are unable to manage them themselves. The home only deals with small amounts of personal monies on behalf of residents. The records for these were viewed and found to be in good order. The system in place ensures that residents can be confident that the monies were handled securely. Staff supervision was again discussed. It had been a requirement from previous inspections that all staff receive structured supervision. On examination of the records it was again found that although this area had improved it was still patchy. The manager is advised to initially monitor how and when supervision takes place. Some senior staff have undertaken supervision training and now feel confident to undertake this aspect of the role, but the whole procedure needs to be better monitored to evidence that it is actually happening on a regular basis. Staff seem to be on the right track but they need to be aware that formal supervision would imply a dedicated time set aside for the member of staff to receive support and supervision from their supervisee. Supervision could take several different forms and cover all aspects of care; philosophy of care in the home and career development needs. It should not be a checklist that is raced through. This was discussed in detail with the manager. Records should be kept to evidence that supervision is taking place. The manager confirmed that staff appraisals have started to take place. During this inspection the inspector again viewed records relating to Health and Safety Procedures, maintenance and servicing, and risk assessments and some significant improvements were noted. The fire doors have been repaired although several were noted as still being propped open. The manager stated that residents did not like their doors shut Grace Manor Nursing Home DS0000026175.V335370.R01.S.doc Version 5.2 Page 22 and that she was in the process of installing sound activated door closures. So far ten had been fitted and she hoped to continue with this work. It was recommended in the last report that the home puts together a fire book that would be stored at the entrance to the home that would provide vital information to any attending fire officer in the event of a fire. It was suggested to the manager that such a fire book could include plan of the fire zones, fire risk assessment location of any oxygen cylinders or explosive / highly combustible materials, evacuation plan, current list of service users and procedures / protocol for evacuating bed bound service users or moving them to another fire zone. This work has been completed. Six members of staff have been trained as Fire Wardens. Additional fire signage has been fitted and six more fire extinguishers have been purchased as recommended by the Fire Risk Assessment carried out by an external company. The fire risk assessment also highlighted the fact that the area known as the ‘Coach house’ was not connected to the general fire alarm system. The home has a duty to ensure that a comprehensive risk assessment is carried out and they must provide adequate precautions to ensure the safety of the residents and staff. The main issue appears to be the failure to maintain the smoke detectors in this area; no evidence was available to confirm regular checks are undertaken. The home is strongly advised to seek advice form their local Fire Safety Officer. The electric cupboards highlighted in the last report now have locks fitted as recommended. The manager confirmed the wardrobes are now secure and that the broken window locks have been repaired. The bathrooms were less cluttered and no evidence of used latex gloves were seen, however two were not operational and this needs to be urgently addressed. All bathrooms now have a thermometer, as recommended in the last report. Portable Appliance Testing has now been completed on all equipment and gas safety checks have been carried out. A new gas cut off valve was in the process of being fitted. The water system has recently been chlorinated and complies with requirements. Water temperature checks are regularly carried out and recorded. The home has two lifts and is currently waiting for some maintenance work to be carried out. All of the hoists were regularly serviced. Grace Manor Nursing Home DS0000026175.V335370.R01.S.doc Version 5.2 Page 23 Again, clearly the home had worked hard to ensure they managed the health, welfare and safety of residents and staff to a much more acceptable level. Grace Manor Nursing Home DS0000026175.V335370.R01.S.doc Version 5.2 Page 24 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 2 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 2 3 2 3 x x 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 2 X 3 Grace Manor Nursing Home DS0000026175.V335370.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP21 Regulation 23(2)(j) Requirement The two broken bath hoist must be repaired to ensure the safety of residents. The fire risk assessment must include adequate precautions and be acted upon for the area known as the ‘Coach house’ to ensure compliance with the Fire Safety Legislation. Timescale for action 30/04/07 2 OP38 23(4)(5) Schedule 4 31/05/07 3 OP33 24 (1)(a)(b) (2)(3) The system used for quality 31/08/07 assurance needs to be extended and the results made available to current and prospective users, their representatives and other interested parties including the CSCI. Grace Manor Nursing Home DS0000026175.V335370.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP9 OP19 Good Practice Recommendations It is recommended that daily record keeping is detailed and consistent. It is recommended that all nurses undertaken a recognised course on the Safe Administration of Medication. It is recommended that consideration be given to the condition of the outside of the building including the driveway. It is recommended that consideration be given to the condition of the window frames It is recommended that larger controlled drugs cabinets are fitted in the medical rooms. 4. 5 OP19 OP9 Grace Manor Nursing Home DS0000026175.V335370.R01.S.doc Version 5.2 Page 27 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 Grace Manor Nursing Home DS0000026175.V335370.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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