Inspection on 28/11/05 for Grange Care Centre, The

This inspection was carried out on 28th November 2005.

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

Grange Care Centre, The 25/09/06

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

CARE HOMES FOR OLDER PEOPLE Grange Care Centre, The The Grange Care Centre 2 Adrienne Avenue Southall Middlesex UB1 2QW Lead Inspector Mrs Clare Henderson Roe Announced Inspection 28th November 2005 10:00 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 Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 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. Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Grange Care Centre, The Address The Grange Care Centre 2 Adrienne Avenue Southall Middlesex UB1 2QW 020 8832 8600 020 8832 8601 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) Life Style Care Plc Ms Deborah Noela Northrop Care Home 160 Category(ies) of Dementia (94), Old age, not falling within any registration, with number other category (46), Physical disability (20) of places Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th June 2005 Brief Description of the Service: The Grange Care Centre is a purpose built care home and is situated in Greenford off the Ruislip Road. It is easily accessed via public transport and the A40. The home is registered to provide care for 94 service users with a diagnosis of dementia, (26 beds for personal care and 68 for nursing care), 46 nursing beds for service users requiring general nursing care and 20 nursing beds for younger adults with physical disability. The home is divided into 8 units. On each unit there are three communal areas. Each unit has two serveries where staff can provide drinks and snacks for service users and visitors. All bedrooms are single with en suite facilities, consisting of toilet and wash hand basin, with 50 also containing shower facilities. There are assisted bath and shower facilities, plus additional toilet facilities in each unit. Each floor has an activities room. On the first floor there is a hairdressing salon and a shop. There is dedicated storage space for the hoists and wheelchairs on each unit. There is a dedicated servicing area on the second floor where the laundry and kitchens are situated. There are several staff changing facilities and two staff rooms, one of which is the only smoking area in the home. A ‘relatives’ room, training rooms and additional staff areas are available on the third floor. There is a well maintained enclosed garden which backs onto the canal. Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of the home since it opened in May 2005, and was an announced inspection. A total of 22 hours were spent on the inspection process. The pre-inspection documentation, completed by the Registered Manager had been received prior to the inspection and 4 relatives comment cards plus 10 service user comment cards were received. The comments made were fed back to the Registered Manager in a general manner. At the time of the inspection, four units only were open. The Registered Manager informed the Inspectors that the remaining units would not be opened until 2006. The Inspectors carried out a tour of the home, and inspected service user plans, staff employment records, training records, maintenance and servicing records. The CSCI Pharmacy Inspector inspected the medication records and management processes. 12 service users, 8 staff and 5 visitors were spoken with as part of the inspection process. There were 67 service users accommodated at the time of inspection. It must be noted that it is sometimes difficult to ascertain the views of service users with dementia care needs. What the service does well: What has improved since the last inspection? This is the first inspection following the homes registration. Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 Page 6 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. Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 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 Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. The home does not provide intermediate care. Service users and their representatives are provided with information about the home. Contracts are completed and provide clear details of the services provided. Service users are assessed prior to admission to ensure the home can meet their needs. Staff have received training to meet service users specialist needs. Prospective service users and their representatives are encouraged to visit the home in order to allow them to make an informed choice. EVIDENCE: Copies of the Statement of Purpose and the Service Users Guide were available in the reception area. The Registered Manager said that the Service User Guide is also available in individual service user bedrooms. The documents were up to date. Two examples of contracts/terms and conditions were shown to the Inspector, one being for privately funded service users and the other for Social Services funded service users. These were clear and comprehensive and detailed the services, fees and terms and conditions of occupancy, plus space for signatures Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 Page 9 of the service user, their representative and the Registered Manager or home representative. The pre-admission assessments carried out by the Registered Manager and the Unit Manager viewed were complete and thorough, and gave a clear picture of the service users needs. In addition, copies of the Social Services needs led assessment or the Primary Care Trust assessments were available. The processes followed ensure that the home can fully meet the assessed needs of the service users. A further assessment is also carried out on the day of admission. Service users and representatives spoken with felt that needs were being met. Staff had received training in the care of service users with dementia. The Registered Manager was working to ensure that each unit is staffed appropriately and stabilised prior to opening any additional units. Relatives and representatives spoken with confirmed that they had been able to visit the home prior to the service user being admitted. Some of these visits had been unannounced and the home had been welcoming of the visits. Where possible service users who are able to make a pre-admission visit to the home are encouraged to do so. Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Service user plans are generally comprehensive and up to date, thus providing a clear picture of the service users needs. Some of the associated documentation required reviewing to ensure that the information is fully up to date and complete, to ensure service users full needs can be met. Medications are well managed at the home, with some minor shortfalls to be addressed to ensure the safety of service users. Staff are courteous to service users and personal support is provided in such a way as to promote and protect the service users privacy, dignity and independence. EVIDENCE: Service user plans were sampled on all four units. Generally these were comprehensive and reflected the needs of the service users. There was evidence of monthly updates plus additional updates as required. The care plans had been signed by the service users or their representative. Risk assessments for falls had been completed and the Registered Manager maintains a comprehensive falls audit and monitors the number of falls, with action plans as appropriate. Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 Page 11 Moving & handling assessments had been carried out but not all documentation had been fully completed on each unit. Details of the moving & handling equipment to be used for each service user had been included. Nutritional assessments had been carried out and monthly weights had been recorded. On one unit a marked weight loss had been recorded but no action had been taken to address this finding, to identify if the recording was inaccurate or not, and whether therefore medical intervention was required. Fluid balance charts and food intake charts had been completed for service users where problems had been identified. Pressure sore risk assessments had been carried out. One viewed did not record a skin break for some months, even though the service user had skin breaks on admission to the home. For another service user who had acquired a sore whilst at the home this had not been identified on the assessment, thus giving an inaccurate record of the risk score. Wound care documentation was generally well completed, with one care plan requiring updating to reflect a change in dressing regime for the service user. For one service user pain control had not been identified in the wound care plan, even though the staff were ensuring pain relief was being offered prior to carrying out the dressing change. The specific pressure relieving equipment in use for each service user had not been clearly identified in the records. Continence assessments had been carried out and associated care plans had been formulated. Risk assessments for the use of bedrails had been completed on all but one unit, and these needed to be completed for all service users who require bedrails. Written consents for the use of bedrails had been obtained. There was evidence of input from the GP and other healthcare professionals recorded in the service user plan. The Registered Manager said that she is clear about the service users entitlements to NHS services. The CSCI Pharmacist Inspector carried out an inspection on 28/11/05 and a separate report is available. The requirements and recommendations resulting from that inspection have been incorporated into this report. Staff were seen speaking with service users in a gentle and courteous manner. Service users spoken with said that the staff were caring towards them, and visitors said that staff always make them feel welcome at the home. One service user commented that ‘nothing was too much trouble’ and there was a positive, homely atmosphere on the units. Service users have access to a payphone or they can have there own telephone in their bedroom. The home has clear policies and procedures for the care of the dying and the care after death, with information regarding many religions contained therein. All bedrooms are single and there is a relatives room should anyone need to stay overnight. The wishes of service users and their representatives in respect of deterioration in the service users’ condition are discussed and recorded. The home has a 24 hour open visiting policy. The Registered Manager said that she was aware of the processes for obtaining input from the Macmillan nursing service. Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The activities provision is generally good and service users have a choice of whether they wish to participate, thus respecting their wishes. Visiting is encouraged and this enhances the service users lives and keeps them in touch with their families and friends. Information regarding advocacy services is freely available, thus ensuring service users rights and interests are upheld. The meals in this home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: At the time of the inspection there was one full time and one part time activities coordinator in post. The Registered Manager said that she was in the process of recruiting a further person to this area of work. A range of activities is offered and information on these was displayed. On both dementia units one Inspector observed activities in progress this included puzzles, colouring, skittles and bingo. Service users appeared to be enjoying these activities and were being encouraged by the staff to participate. Activities were available on each unit. Care plans for social and leisure activities were somewhat general in content and needed personalising to each individual, so that a clear picture of their interests can be gained and the activities programme planned accordingly. Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 Page 13 There is a 24 hour open visiting policy and visitors spoken with said that they were made to feel welcome at the home. Also, that if there are any accidents or incidents then the next of kin is contacted. Service users can choose whom they wish to see and their wishes are recorded and respected. Links are being forged with the local school, Age Concern and the local churches. Information on how to contact advocacy services is available through Care Aware and other advocacy services was available at the home. At the time of the inspection service users representatives were managing service users finances. Both Inspectors observed the lunchtime meal. Service users were seen to be enjoying their meals and assistance was provided in a discreet and sensitive manner. The menus viewed did not always offer a choice of main meal, and it was not clear what options were available. Service users asked said that they are not offered a choice. Choice lists were available in the kitchen, and the need to review the menu to ensure all choices are included and that service users are offered that choice was discussed. Service users said that the breakfast meal is very good, with a full cooked option being available. The supper menu is regularly reviewed, with service users choices being accommodated. It was noted that fridge temperatures in the serveries were not always being recorded daily, and the Registered Manager said that this would be addressed immediately. The kitchen was clean and tidy and all the cleaning and temperature records were up to date. Foodstuffs viewed were in date and stored appropriately. Staff handling food had received food hygiene training. The Inspectors sampled the meat and vegetarian lunchtime meal options, and these were well presented and tasty. All bedrooms viewed had water jugs and drinking glasses available. Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 The home has a satisfactory complaints system with evidence that service users and representatives concerns are listened to and acted upon. Service users rights are protected and service users are able to exercise their legal rights directly. Staff have knowledge and understanding of adult protection issues which protect service users from abuse. EVIDENCE: The home has a clear complaints procedure, which provides contact details for the home, the head office and the CSCI. 4 complaints had been received and these had been comprehensively recorded, with letters of outcome evidenced. Service users and visitors spoken with confirmed that they were aware of the complaints procedure and that any concerns raised were addressed. The Registered Manager said that service users have been registered on the electoral role, and that she was aware of their rights to vote if they so wished, and would facilitate this. Information regarding advocacy services was on display in the home. The Registered Manager was clear about the protection of vulnerable adults (POVA) procedures to be followed in the event of an allegation. Staff spoken with showed a clear understanding of POVA and Whistle Blowing procedures, and said that they would report any concerns. Staff had received POVA training. Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 The home is purpose built and has been built in accordance with the National Minimum Standards for Older People and Younger Adults. The décor is of a good standard throughout, as are the fixtures, furnishings and fittings, thus providing a pleasant and homely atmosphere for the service users. Infection control procedures are adhered to, thus safeguarding service users. EVIDENCE: The location and layout of the home is suitable for its stated purpose. It is accessible, safe and well maintained and meets the service users individual and collective needs. All environmental checks had been carried out as part of the registration process, to include fire safety and environmental health inspection. The grounds are safe and attractive and accessible to service users. CCTV cameras are located at the entrance and exit areas for security purposes. Communal space is available on each unit. This includes lounge and dining areas and an activities room. Furnishings viewed in the communal areas were of good quality and met the needs of service users, to include differing height armchairs. Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 Page 16 Each bedroom has en suite facilities and suitable assisted bathing, shower and toilet facilities are available throughout the home. The home has been purpose built and suitable adaptations, moving & handling equipment, height adjustable beds and corridor rails are available throughout the home. Service users bedrooms viewed were spacious and contained the required furnishings and fittings. Thought had gone into the matching of the décor with the furnishings. Bedroom doors were lockable with keys provided unless a service user was assessed as being unable to manage the key. Alternative flooring was viewed in some bedrooms where carpets were not appropriate. All radiators are guarded and can be controlled individually. The home was warm throughout. Lighting was satisfactory and there is emergency lighting throughout the home. Call bells were available in all the rooms on each unit where service users may be accommodated, and were being answered promptly. There was evidence of hot water temperatures and the emergency lighting being regularly checked by the maintenance man. The laundry room was clean and tidy. There are four washing machines and four tumble dryers available. The laundry person said that she ensures that the personal laundry for each unit is kept separate, and labels to evidence this were available. Most of the personal laundry is labelled, and individual boxes for each unit are kept for any unlabelled items that staff do not recognise, so that service users or relatives can be shown these and look for any missing items. The home was clean throughout and smelled fresh. Protective clothing was available plus liquid soap and paper towels were seen in all areas where service users, staff and visitors may require to wash their hands. Infection control procedures were available in the laundry and kitchen areas and also in the main policy and procedure files. Individual sluice rooms were available on each unit and are maintained locked when not in use. Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The home was adequately staffed to meet the needs of the service users. Systems for vetting and recruitment practices are in place and protect service users. Staff had received mandatory training and also training in topics relevant to their roles, thus providing them with the knowledge to care for service users appropriately and safely. EVIDENCE: The Registered Manager stated that the home was operating variable staffing levels as the units are not yet fully occupied. This had been agreed with the CSCI at the point of registration. This standard will be examined in full at the next inspection. Generally the staffing levels were appropriate to meet the needs of the service users and it was clear that the Registered Manager monitors the level of dependency on each unit regularly to ensure staffing is maintained at required levels. On the day of inspection one unit was short of one member of staff in the afternoon, however it had not been possible to cover the shift at short notice. Some relatives did comment that on some units they would like to see a member of staff in the lounge with the service users, but did accept that this may not always be possible at all times. The home has 11 care staff with NVQ level 2 or above in care. 12 staff are commencing NVQ level 2 in care in January 2006 and thereafter the Registered Manager stated that she would have a rolling programme in place. There was evidence that induction training undertaken by all staff met the Skills for Care (formerly TOPSS) core standards. The Registered Manager stated that foundation training would be implemented in the near future. Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 Page 18 Three sets of staff employment records were viewed. These contained the information required under the Care Homes Regulations 2001. An additional set of staff records was viewed and there was evidence that a work permit had been obtained prior to offering employment to the individual. The home did not have any volunteers at the time of inspection. A training matrix was seen, and lists of staff training are maintained on each staff file. It was clear that staff have ongoing training, for both mandatory and relevant topics to provide them with the knowledge to care for service users with specific diagnoses. Staff receive a minimum of 3 paid days training per year, and the training records evidenced time in excess of this. Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 and 38 The Registered Manager has a clear plan and vision for the home, which she has effectively communicated to service users, staff and visitors. The Registered Manager is well supported by the staff and provides clear leadership throughout the home, with all staff demonstrating an awareness of their roles and responsibilities. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Systems for the management of service users monies are in place and secure facilities are available. Staff receive supervision, thus promoting communication and review of practice. Records are well maintained for the protection of service users and the running of the home. Systems for the management of health and safety throughout the home are good, thus safeguarding service users, staff and visitors. EVIDENCE: The Registered Manager is an registered nurse in mental health and has completed the Registered Managers Award. She has been managing care homes with nursing for several years, and has a good knowledge of her role. Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 Page 20 The Registered Manager has undertaken ongoing training relevant to her role and said that her job description enabled her to take responsibility for fulfilling her duties. There are clear lines of accountability within the home and within Life Style Care plc. The Registered Manager has an open attitude and service users spoken with said that she visits them on the units each day. Visitors said that any concerns are dealt with promptly and that the Registered Manager is very approachable. She adopts an ‘open door’ policy for all comers. The Registered Manager provides a clear sense of direction and leadership. The home has an action plan, which details evidence of planning for the present and the future, with review. Auditing systems are in place, and there was evidence of action plans to meet any shortfalls identified during the auditing processes. Staff, service user and relative meetings are held and minutes of these meetings are available. The home has a comment box and it was clear that visitors have utilised this service positively. Any concerns raised via this method are addressed promptly by the Registered Manager, and a written record of the action taken is maintained. Many of the comments were very positive. Information regarding the CSCI inspection had been advertised throughout the home. Comment cards received by the CSCI were positive and any comments made were fed back in a general manner to the Registered Manager. Regulation 26 visits take place each month and a copy of the report is sent through to the CSCI. Insurance cover for Employers Liability was current and the certificate was on display in the home. The Life Style Care plc general insurance policy covers buildings and other aspects of insurance required. The home has copies of the Life Style Care plc procedures for dealing with service users personal monies. The home currently does not hold any monies on behalf of service users. A safe facility is available within the home. Service users have a lockable space in their bedrooms. A system for staff supervision was in place and the matrix viewed showed that this had been implemented. All staff receive training for supervision to ensure that they understand the processes for this. There was also evidence of separate staff appraisals. Records are stored securely within the home. These are generally kept up to date and were systematic and easy to locate. Service users have access to their personal records should they so wish. There is a clear matrix of mandatory and additional training maintained. Servicing and maintenance records were viewed at random and were found to be up to date and in order. All commissioning certificates and documentation were available. There is a clear health & safety policy in place. Risk Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 Page 21 assessments for all areas of risk to include the kitchen and laundry areas were in place, and copies were available throughout the home. Accidents were clearly recorded and the Registered Manager audits and monitors the number of accidents throughout the home. Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 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 3 3 3 3 3 3 3 Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? N/A 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 2 3 Standard OP8 OP8 OP8 Regulation 13(5) 12 17 Requirement Moving & handling assessments must be completed and kept up to date. Any unexplained weight loss must be investigated and addressed. Pressure sore risk assessments must be accurately completed. Wound care documentation must be updated in line with any changes in dressing regimes. Prior to use a full assessment for the use of bedrails must be completed and there must be evidence that the use of bedrails is appropriate for the service user. Instructions for pain control in relation to any procedure must be recorded in the service user plan. Pressure relieving equipment in use must be clearly identified for each individual. Medicines must be recorded accurately after service users have received their medicines. If a variable does is prescribed then the actual dose DS0000063541.V259170.R01.S.doc Timescale for action 01/12/05 01/12/05 16/12/05 4 OP8 13(7) 16/12/05 5 OP8 12 01/12/05 6 7 OP8 OP9 17 13(2) 16/12/05 01/12/05 Grange Care Centre, The Version 5.0 Page 24 8 OP9 13(2) 9 10 OP9 OP9 13(2) 13(2) 11 OP12 15(1) 12 OP15 16, 17 administered must be recorded. Homely remedies must be recorded accurately. Dosage changes must be clearly re-written on the medication administration record (MAR). Labels must correlate with instructions on the MAR. Adhesive labels must not be placed on the MAR. There must be no crossing out or Tippex used in the Controlled Drug register. Dates of opening must be written on medicines with a limited shelf life so that they are not used past their expiry date. The care plans for each service users social and leisure interests must reflect their individual needs and identify how these are to be met. A choice of meals must be available to service users and these choices must be discussed, recorded and respected. 07/12/05 01/12/05 14/12/05 16/12/05 16/12/05 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 OP27 Good Practice Recommendations That the MDS blisters are kept in the same order as the medicines are listed on the MAR. It is recommended that a member of staff be present in the lounge areas to supervise service users and help maintain their safety. Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Grange Care Centre, The DS0000063541.V259170.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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