Inspection on 15/09/05 for Grange Cottage Residential Home

This inspection was carried out on 15th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Grange Cottage Residential Home 07/04/09

Grange Cottage Residential Home 29/04/08

Grange Cottage Residential Home 07/11/07

Grange Cottage Residential Home 02/05/06

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

CARE HOMES FOR OLDER PEOPLE Grange Cottage Residential Home 6 Grange Road Sutton Surrey SM2 6RT Lead Inspector Mohammad Peerbux Unannounced Inspection 15th and 23rd September 2005 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 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 Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Grange Cottage Residential Home Address 6 Grange Road, Sutton, Surrey, SM2 6RT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8642 2721 Grange Cottage Residential Home Mr Derek Read Care Home 11 Category(ies) of Dementia - over 65 registration, with number Mental Disorder - over 65 of places Grange Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: A variation has been granted to allow two specified service users under the age of 65 to be accommodated until such time that the home is unable to meet their assessed needs or their placement terminates. Date of last inspection 9th of May 2005 Brief Description of the Service: Grange Cottage is a small residential home registered for eleven service users over the age of 65, who suffer from long term mental health problems including dementia. Two service users are under the age of 65 and variations of registration have been issued for both of them.They have both been there for some while and this home continues to meet their needs fully. The home has applied for another variation to admit a service user under the age of 65. This is being processed at present.The accommodation is provided over two floors; there is no lift however all the service users are able to use the stairs. There are nine single bedrooms and one shared room. All the bedrooms have washbasins. There is parking to the front of the property and a pleasant garden to the rear. The home is well served by public transport routes. Grange Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second inspection for the year 2005/06. It was an unannounced inspection and took place over one day. Some time was spent looking at the policies and procedures, talking to staff, the acting manager and to two of the service users. A tour of the building was also carried out. During the inspection it was noted that the home had admitted a service user for whom they had applied to the Commission For Social Care Inspection for a variation to the homes registration before the relevant paper work had been completed. Although the home received verbal confirmation from CSCI that the variation would be approved, the home manager was reminded that as the application had not yet been agreed that the service user had been moved in out of category and that the home should have waited until the application had been formally agreed. An immediate requirement was also issued as one member of staff was working without a POVA or CRB check. What the service does well: What has improved since the last inspection? Some of the carpets in the bedrooms have been renewed and the home is now free from offensive odours. The copper pipes in room 2 have been covered to prevent service users from scalding. Grange Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 Page 6 What they could do better: The home must make available to all service users an up-to-date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions. The home must also produce a Service Users Guide and shall supply to each service user and to the Commission. The service user’s plans need to be reviewed and updated by care staff in the home at least once a month, to reflect changing needs and current objectives for health and personal care, and actioned. The medication administration records must be accurately completed at all timesand the policy needs amending to include how receipt of medications will be recorded. Medicines in the custody of the home must be handled according to the requirements of the Medicines Act 1968, guidelines from the Royal Pharmaceutical Society and the requirements of the Misuse of Drugs Act 1971. The service users and/or their relatives must be consulted about their last wishes and these need to be documented in their personal files. The complaints procedure must be amended to include the stages and timescales for response. Written guidelines need to be in place on how to deal with the service user who can be physically aggressive.This must be discussed with the service user and his relatives. All staff must be aware of the adult protection policy and procedures and must receive training on Abuse. Any bedroom doors, that service users wish to leave open,must have magnetic catches of a type that close the door automatically in the event of a fire, fitted. Staff files must contain all relevant documentations as per schedule 2 of the revised Care Homes Regulations 2001 and any care worker who works with service users has received an appropriate CRB (Criminal Records Bureau) check, validating that the person has been vetted as being safe to work. The quality assurance surveys need to be extended from service users, relatives and friends to include visiting professionals and any other stakeholders. An annual QA Development Plan must be produced. This should include feedback from the surveys and assess the extent to which the home’s aims and objectives are being met. Formal supervision sessions need to be held with all care staff at least six times a year, and that these sessions are recorded and signed by both the supervisor and supervisee. Grange Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 Page 7 The home must have a policies and procedures checklist. This should list all of the home’s policies and procedures, indicating when each policy was last reviewed. A copy should be included in each staff file, and should evidence that staff have read and understood each policy developed and reviewed. It is recommended that a risk assessment is carried out on the service user who self-medicate. It is recommended that the activities timetable is displayed on the notice board and it is circulated to all service users in formats suited to their capacities. 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 Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Grange Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 3 The home does not provide sufficient information for prospective service users to be clear about the service the home provides to meet their needs, as no Statement of Purpose and Service User’s guide were available at the times of inspection. The home undertakes a comprehensive assessment of the healthcare needs of service users prior to their admission to ensure their needs can be met by the home and their rights are enhanced through their contract with the home. EVIDENCE: The acting manager was not able to produce a copy of the homes Statement of purpose on request and he advised the document was being reviewed. So prospective service users will not have the information they need to make an informed choice about where to live. There was no evidence that the home has a Service User’s Guide on the day of the inspection. The acting manager stated that the Service User’s Guide has been produced and it was with the registered provider. This was a requirement from the last inspection and the timescale for action was 30/06/05. Grange Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 Page 10 The registered person must produce and make available to service users an up-to-date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users’ guide to the home for current and prospective service users. The registered provider must take urgent action to resolve these ongoing issues. During the inspection it was noted that the home had admitted a service user for whom they had applied to the Commission For Social Care Inspection for a variation to the homes registration before the relevant paper work had been completed. Although the home received verbal confirmation from CSCI that the variation would be approved, the home manager was reminded that as the application had not yet been agreed that the service user had been moved in out of category and that the home should have waited until the application had been formally agreed. This is an offence under Section 24 of the Care Standards Act 2000. There was evidence that service user who had recently been admitted, had a full care needs assessment in place and these forms the basis for the care plans. Prior to admission the acting manager went to visit and assess him. A copy of the assessment was seen. Grange Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,9,10 and 11 Service users’ health, personal and social care needs are not being appropriately met as their care plans are not being reviewed and updated to reflect their changing needs. The systems for administration of medication are poor and potentially place service users at risk. EVIDENCE: Service users’ care plans clearly set out the action staff needed to meet individual service user’s personal, social and health care needs. However it was noted that the care plans are not being reviewed and updated to reflect the changing needs and current objectives for health and personal care, and actioned. The acting manager is aware of this issue. At the last inspection the acting manager stated that the care plans were being reviewed however during this visit some care plans were sampled at random and they have not been reviewed since last year. The registered person must ensure that service user’s plans are reviewed by care staff in the home at least once a month, updated to reflect changing needs and current objectives for health and personal care, and actioned. Grange Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 Page 12 The administration records were also audited. There were two instances where prescribed medication had been omitted or administered but not signed for. While it transpired that there were acceptable explanations for this, these explanations had not been recorded. In all cases where medication is not given as prescribed, staff must ensure that they record the reason for this. The registered person must ensure that medication administration records are accurately completed at all times. This was a requirement from the previous inspection. It was previously required that the medication policy needs amending to include how receipt of medications will be recorded. The medication policy was not available at the times of inspection and there was no evidence that this has been met and therefore this requirement will be repeated. It was previously recommended that a risk assessment is carried out on the service user who self-medicate. The acting manager was not able to evidence this has been achieved and therefore this recommendation will be repeated. During the inspection it was noted that a tube of “Lasonil” ointment 40g was on the floor in the office by the filing cabinet. The acting manager was not able to comment on how that medication got there. This potentially places service users at risk .The registered person must ensure that Medicines in the custody of the home are handled according to the requirements of the Medicines Act 1968, guidelines from the Royal Pharmaceutical Society, the requirements of the Misuse of Drugs Act 1971. Failure to comply with the aforementioned requirements represent serious breaches of the Regulations and urgent action must be taken by the registered persons to address these to avoid the Commission taking further action to enforce compliance. Observation of the staff team interacting with the service users showed that the carers were mindful how they addressed service users, and they were seen to be polite and friendly. A visiting relative commented positively about the care her mother is receiving. It was previously required that the manager must consult the service users and/or their relatives about their last wishes and this needs to be documented in their personal files by 30/09/05.There was no evidence that this has happened or in the process of being done and therefore this requirement will be repeated.The acting manager stated that only two service users have their last wishes documented in their personal files. Grange Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 Service users are being provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and religious needs. EVIDENCE: Service users are evidenced as being provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and religious needs. A new timetable of activities for service users has been produced. It was recommended that the timetable is displayed on the notice board so all service users can have access to it. However the timetable was in the office and therefore this recommendation will be repeated. It is also recommended that the timetable is circulated to all service users in formats suited to their capacities. Grange Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 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 standard(s) 16 and 18 Service users, their relatives and friends cannot be confident that their complaints will be taken seriously and acted upon as no complaints policy and procedure was in place. Staff need to be aware of the adult protection policy and procedures and have training on abuse in order to protect service users. EVIDENCE: It was previously required that the manager must review the complaints procedure to include the stages and timescales for response.However the acting manager was unable to show evidence that this has been met and therefore this requirement will be repeated. There is one service user who can be physically aggressive at times. The manager was required to ensure that written guidelines are in place on how to deal with this situation and this is discussed with the service user and his relatives. No guidelines were in place at this inspection so this requirement will be reinstated. As part of the inspection process one staff member was interviewed. She was not aware of the adult protection policy and procedures .The registered provider must ensure that all staff are aware of the adult protection policy and procedures and must receive training on Abuse. Grange Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 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 standard(s) 19,24 and 26 The home is generally hygienic and clean, homely and comfortable; this environment therefore facilitates the residents’ health and emotional wellbeing. Fire Safety issue still need to be addressed as this potentially place service users and staff at risk. EVIDENCE: The home is basically well maintained, with an ongoing internal decoration programme. The home has a separate kitchen, laundry facilities, and a small office. Some of the carpet in the bedrooms have been renewed. A requirement was set at the last inspection that the registered provider must ensure that any bedroom doors, that service users wish to leave open, have magnetic catches of a type that close the door automatically in the event of a fire, fitted. This remains outstanding. This requirement will be repeated as Grange Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 Page 16 failure could results to serious repercussions to the health and welfare of service users. The home is kept very clean and hygienic and free from offensive odours throughout. Grange Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 and 30 The home was evidenced to have the numbers and skill mix of staff sufficient to meet service users’ needs and ensure their safety. One concern was identified in regard to recruitment checks not being completed satisfactorily, which impinge on the safety and protection of service users being ensured. EVIDENCE: Copies of the off duty rotas were seen. The home was evidenced to have the numbers and skill mix of staff sufficient to meet service users’ needs. There are always three carers on duty in the home during the day. At night there is one member of staff awake and one sleeping in. It was previously required that the manager must ensure that staff files must contain all relevant documentations as per schedule 2 of the revised Care Homes Regulations 2001.The acting manager was not able to access staff files as he did not have the key and therefore this requirement will be repeated. As part of the inspection process one staff member was interviewed. It transpired that she was working without a Criminal Record Bureau check or a POVA check. An immediate requirement was issued and the staff member was sent home. A letter was received at CSCI from the provider following the inspection stating that the staff has been suspended. The registered provider is Grange Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 Page 18 again reminded to ensure that any care worker who works with service users has received an appropriate CRB (Criminal Records Bureau) check, validating that the person has been vetted as being safe to work. It was previously recommended that staff names are recorded when they attend the fire training for easy monitoring.This is now in place. Grange Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,36,37 and 38 The quality assurance processes needs to further develop so as to include the views of visiting professionals and other stakeholders to ensure that the home is run is in the best interests of the service users. One-to-one supervision sessions are still not being held with staff on a regular basis, this could affect the staff’s ability to consistently meet the service users’ needs. EVIDENCE: It was previously required that the Manager must ensure that quality assurance surveys are extended from service users, relatives and friends to include visiting professionals and any other stakeholders. This remains outstanding and the requirement will be repeated. Grange Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 Page 20 It was previously required that the Manager must ensure that formal supervision sessions are held with all care staff at least six times a year, and that these sessions are recorded and signed by both the supervisor and supervisee.Again this remains outstanding and the requirement will be repeated. It was previously required that the home must have a policies and procedures checklist. This should list all of the home’s policies and procedures, indicating when each policy was last reviewed. A copy should be included in each staff file, and should evidence that staff have read and understood each policy developed and reviewed. Again this remains outstanding and the requirement will be repeated. Not all records required for regulation were in place at the times of inspection. It was previously recommended that a risk assessment is carried out on the copper pipes in room 2 to prevent the service user from scalding. The pipes have now been covered. Grange Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x 2 x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x 2 x 2 x 2 3 Grange Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 Page 22 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4 Requirement Timescale for action 30/11/05 2. 1 3. 7 4. 9 5. 9 The registered person must produce and make available to service users an up-to-date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home. 5(1)(2)(3) The home must produce a Service Users Guide and shall supply a copy to the Commission and each service user.(Previous timescale of 30/06/06 not met). 15(2)(b) The registered person must ensure that service user’s plans are reviewed by care staff in the home at least once a month, updated to reflect changing needs and current objectives for health and personal care, and actioned. 13(2) The registered person must ensure that medication administration records are accurately completed at all times.(Previous timescale of 09/05/05 not met) . 13(2) The medication policy needs amending to include how receipt of medications will be recorded.(Previous timescale of G53 S61844 GrangeCottage V230829 150905 stage4.doc 30/11/05 30/11/05 15/09/05 30/11/05 Grange Cottage Residential Home Version 1.40 Page 23 30/06/06 not met) . 6. 9 13(2) The registered person must ensure that Medicines in the custody of the home are handled according to the requirements of the Medicines Act 1968, guidelines from the Royal Pharmaceutical Society and the requirements of the Misuse of Drugs Act 1971. The manager must also consult the service users and/or their relatives about their last wishes and this needs to be documented in their personal files.(Previous timescale of 30/09/05 not met). The manager must review the complaints procedure to include the stages and timescales for response.(Previous timescale of 30/09/05 not met) . The manager must ensure that written guidelines are in place on how to deal with the service user who can be physically aggressive.This must be discussed with the service user and his relatives. (Previous timescale of 30/06/05 not met) . The registered provider must ensure that all staff are aware of the adult protection policy and procedures and must receive training on Abuse. The manager must ensure that any bedroom doors, that service users wish to leave open, have magnetic catches of a type that close the door automatically in the event of a fire, fitted. (Previous timescale of 28/02/05 and 30/06/05 not met). The manager must ensure that staff files must contain all relevant documentations as per schedule 2 of the revised Care Homes Regulations 15/09/05 7. 11 12(3) 30/11/05 8. 16 22(4) 30/11/05 9. 18 13(7)(8) 30/11/05 10. 18 13(6) 30/11/05 11. 24 13(4)( c ) 30/11/05 12. 29 19(1)(b) 30/11/05 Grange Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 Page 24 13. 29 19(1)(b) 14. 33 24(1)(a) & (b) 15. 33 24(2) 16. 36 18(2) 17. 37 12(1)(a), 18(1)(a) 2001.(Previous timescale of 30/09/05 not met) . The registered provider must ensure that any care worker who works with service users has received an appropriate CRB (Criminal Records Bureau) check, validating that the person has been vetted as being safe to work.An immediate requirement was issued on the 15/09/05 regarding one staff working without a CRB and/or POVA check. The registered provider must ensure that quality assurance surveys are extended from service users, relatives and friends to include visiting professionals and any other stakeholders.(Previous timescale of 30/09/05 not met) . The Registered Manager must ensure that an annual QA Development Plan is produced. This should include feedback from the surveys and assess the extent to which the home’s aims and objectives are being met.(Previous timescale of 30/09/05 not met). The Manager must ensure that formal supervision sessions are held with all care staff at least six times a year, and that these sessions are recorded and signed by both the supervisor and supervisee.(Previous timescale of 30/06/05 not met). The home must have a policies and procedures checklist. This should list all of the home’s policies and procedures, indicating when each policy was last reviewed. A copy should be included in each staff file, and should evidence that staff have read and understood each policy 30/11/05 30/11/05 30/11/05 30/11/05 30/11/05 Grange Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 Page 25 developed and reviewed.(Previous timescale of 31/08/05 not met). 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. 4. Refer to Standard 9 12 12 Good Practice Recommendations It is recommended that a risk assessment is carried out on the service user who self-medicate. It is recommended that the activities timetable is displayed on the notice board . It is also recommended that the activities timetable is circulated to all service users in formats suited to their capacities. Grange Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 Page 26 Commission for Social Care Inspection 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Cottage Residential Home G53 S61844 GrangeCottage V230829 150905 stage4.doc Version 1.40 Page 27 - 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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