Inspection on 13/11/06 for Grange Lea Residential Home

This inspection was carried out on 13th November 2006.

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 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 Lea Residential Home 24/02/06

Grange Lea Residential Home 08/09/05

Grange Lea Residential Home 08/02/05

Grange Lea Residential Home 17/06/04

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

CARE HOMES FOR OLDER PEOPLE Grange Lea Residential Home Grange Road Off Wigan Road Bolton Lancashire BL3 5QE Lead Inspector Sue Donovan Unannounced Inspection 13th November 2006 08:30 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 Grange Lea Residential Home DS0000009287.V308215.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. Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grange Lea Residential Home Address Grange Road Off Wigan Road Bolton Lancashire BL3 5QE 01204 665903 01204 650112 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) Dr A Joy Kumar Ghosh Mrs Glynis Roberts Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. That within the maximum number of 26 there can be up to 26 OP. Date of last inspection 24th February 2006 Brief Description of the Service: Grange Lea is a privately owned care home for 26 older people of either sex. The home is in a residential area close to Bolton town centre, and is close to several local amenities including shops, a park and coffee shop. Grange Lea has 22 single bedrooms and two double rooms. 6 rooms have en-suite facilities. There are two floors with a lift to the first floor. The home has a good choice of lounge areas, a small garden area and car park. Fees currently range from £309.88 to £350.00 per week. Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was not told that the inspection was to take place. The visit took place over eight hours from 8.30am to 4.30 pm. The report was written after looking at the information sent to the commission for social care (CSCI), including comment cards from a doctor and two relatives, and after talking to the residents of Grange Lea, their relatives, the manager and staff and looking around the home. During the inspection care and medicine records were looked at to make sure resident’s needs were being met. The inspector looked around the building at the lounges, bathrooms, dining room and toilets to check if they were clean and well decorated. The inspector looked at what meal was provided for lunch, how resident’s money was looked after and checked records to see how the home and the equipment was kept safe. A copy of the last inspection report is kept in the reception area with the service user guide and the complaints procedure. No complaints had been received by the CSCI since the last inspection and relatives confirmed that they knew how to make a complaint. Residents said, “on the whole it’s a happy place” and “it’s a friendly place” but one resident said, “Time does drag” What the service does well: The home is very homely and welcoming. The manager has worked at the home along time and knows residents very well. One resident said,” the manager is lovely.” The staff that work in the home are good at supporting residents the way they want to be supported and many were trained to do their jobs. (National Vocational Qualifications –NVQ) The assessments (what is written so residents needs can be met) are very clear and have some good detail in them for example, “ likes pies from greenhalghs”. Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Residents and their families should be involved in saying what goes into their care plan. Residents/families should see the care plans and be involved in any changes made to them. A resident said, “I haven’t seen my care plan”. The home should make a plan of activities that residents can take part in. This plan should show what is available both in the home and in the community. Residents and families should be asked what type of activities they would enjoy. One resident said, “time does drag”. How to complain should be written so everyone can see and understand it for example in large letters with photographs of who to complain to. Staff files should have more information on them including a phoograph. Residents and their families and friends should be asked what they think of the home and the results used to improve the service. Please contact the provider for advice of actions taken in response to this Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 Page 7 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. Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective residents have their needs assessed prior to admission to assure these will be met. EVIDENCE: A statement of purpose and service user guide was available and displayed in the entrance of the home. The service user guide was easy to understand but could be made more attractive and clearer by using photographs and symbols. A discussion took place with the manager regarding the assessment process that was undertaken when someone wanted to come and live at the home. She said that a senior member of staff visits the person at home or in hospital to Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 Page 10 assess them and if possible they visit the home. One resident confirmed she had visited the home before making a decision. Four residents files were looked at and showed that assessments had been undertaken. One resident who was funded by social services had a care management assessment on their file. The assessments although brief covered all relevant areas and included social contacts, communication, personal details and a photograph. On three of the files loose notes with contact numbers were held, these should be written into the personal details of residents. Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a clear, consistent care planning system in place to provide staff with the information they need to satisfactorily meet residents needs, however residents/relatives are not involved limiting their right to have a say in the care they need. The medication at the home is now well managed promoting good health. EVIDENCE: The care plans of four residents were looked at. The plans contained information about how to care for residents and what residents liked and disliked. The care plans include washing and bathing, continence, eating and drinking, sight and hearing, social activities /contacts and sleeping patterns. The plans were very clearly written but could include more information. A life history Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 Page 12 section, including extended family, and an area documenting resident’s interests and hobbies could be added. The eating and drinking section of the care plan showed food preferences for example, “ likes meat pies from Greenhalghs” and “doesn’t like crusts on bread or toast”. The manager said that care plans are reviewed monthly, two plans read had been reviewed 17/10/06 and 26/10/06 but two had not been reviewed since 25/09/06. Daily records where up-to-date showing for example how residents health was, or who had visited. Key worker sheets were also on files, on one file this had never been completed and on others only a few recorded entries were seen. If it is the homes policy for key workers to make observations and complete sheets to show outcomes for residents and contact with relatives, then these should be used. It was observed during the inspection the manager asking a member of staff that had been on sick leave, to update herself by reading the care plans of the two newly admitted residents. The service user guide says in the Health and Welfare section,” we will work with your social worker and family to develop a care plan that is individual to you” “ you are able to see your care plan whenever you wish, we will make sure you understand everything that is in your file”. There was no evidence on files that residents or families had been involved in compiling the care plan, one resident said “ I haven’t seen my care plan, I thought I must have one”, and a relative said ,” I‘ve not seen a care plan”. This needs to be addressed to ensure there is evidence residents and/or their representatives have been consulted about their plans to deliver care. Nutrition assessments were seen on files and health records showed that weight is monitored monthly to ensure resident’s health is maintained. All residents have access to a range of health professionals. Records looked at detailed doctors, chiropodist and hospital visits. The chiropodist was in the home on the day of the inspection. A comment card from a doctor showed no concerns about health care standards at the home. The pharmacy inspector carried out two pharmacy inspections, 24/08/06 and 29/08/06. The first visit raised concerns regarding the management of medication and requirements were made. The second inspection showed good practice in the management of the medicines and the medication round. It was observed that medicines were administered to one resident and the records completed before beginning administration to another resident. None of the residents had chosen to self-administer medication, but the home had a policy to support a resident if they wished to do so. A resident commented that staff respected their privacy and dignity by always knocking on doors. Staff were observed assisting residents in a sensitive way, Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 Page 13 for example straightening clothing discreetly and using residents preferred name. Staff were also seen encouraging residents to be as independent as possible by doing small things for themselves. Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The frequency of social activities is poor and the lack of opportunities for residents to access community facilities limits resident’s opportunities for a lifestyle of their choice. Visiting arrangements in the home are good ensuring links between residents and their families and friends are maintained. Meals are adequate providing a balanced diet with limited choice for residents. EVIDENCE: No activities programme was seen. Residents spoken with said a lady came in some Thursdays for craft. One resident said,” Time does drag.” The manager said that the staff sometimes organise games and quizzes. A member of staff was observed playing skittles with a few residents on the day of inspection. A hairdresser visits weekly. There was no evidence of any activities currently being arranged outside the home. One member of staff said,” going out more” would improve things The manager said she had recently registered some Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 Page 15 residents with the local dial–a–ride scheme and was going to organise some community access. An activity plan needs to be developed and activities in the community incorporated into this. Staff were seen spending time chatting to residents. One member of staff confirmed that the manager encourages staff to take time to talk with the residents. All residents were white British, residents religious beliefs were written into care plans and a priest visits the home on a Sunday at the request of some residents. The home has an open visiting policy. There are no restrictions on the time relatives and friends can visit. Visitors were observed at various times during the day. A visitor’s book showed the times people had visited. The manager, deputy and staff were very welcoming and visitors said they always felt comfortable coming into the home. One relative said, “ It’s a friendly place”. Residents were seen to have many of their personal possessions around them these included furniture, ornaments and pictures. The two-week rotating menus sent with the pre-inspection questionnaire showed food to be varied and a limited choice offered. Food preferences of residents were written into care plans. The lunchtime meal was observed. The dining room was homely and tables were set with white tablecloths. The cook served the meal and care staff served the residents. The meal consisted of beef stew, mashed potato and green beans followed by apple crumble and custard a jug of cordial was provided on the tables but no hot drink was offered. It was observed that the crumble was very hard and some residents struggled to eat it, a resident said” I’ve had better”. It was observed during the inspection that one resident who didn’t want the hot meal had a sandwich and another choose ice cream for her dessert. Another resident said that the food was not bad but that some days were better than others. The cook was starting a ‘safer food better business’ action plan and was looking forward to the involvement of a mentor to help her to make any necessary changes. Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complains system with some evidence that residents feel that their views are listened to. EVIDENCE: A complaints procedure was in place. The procedure was displayed in the reception area of the home. A complaints book was examined to find that nine complaints had been documented, seven from the same complainant. It was suggested that the pages in the book be divided to show action taken, within what timescales. The complaints procedure on display should be written in a user-friendly format so everyone could understand it, for example using large font, photographs and symbols. No formal complaints had been received by the CSCI since the last inspection. Feedback from relatives who returned comment cards indicated they were aware of the procedure to take when making a complaint The home had received a number of compliments and it was suggested that a compliments/achievements file could be used and the comments fed back to staff. A resident said, “on the whole it’s a happy place, I would say if I wasn’t happy”. Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 Page 17 A procedure for responding to allegations of abuse (including whistle blowing) was available as was the Bolton safeguarding adults policy. Staff spoken with understood the importance of reporting bad practice and were aware of the different types of abuse. Records showed training in safeguarding adults had taken place in February 2006. Staff training records inspected showed not all staff had received training in abuse awareness this needs to be checked. Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A safe building was provided for residents. For residents comfort attention needs to be paid to decorating and upgrading of some fittings. EVIDENCE: Grange Lea is a large detached property in Bolton. The home is situated in a residential area just off the main road into the town. Car parking is available at the front of the home. There are safe small seating areas with raised beds at the front and rear of the property. As a security measure the front door is locked. Level access was provided to the home, along with a passenger lift to Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 Page 19 the upper floor. Two baths are fitted with hoists. It was noted that the downstairs toilet was in need of decorating. The wallpaper was peeling off. The large downstairs lounge is comfortable adequately decorated and furnished. Two other lounges ensure a good choice of communal areas. Smoking was allowed in the small lounge. A small hairdressing salon was seen being used on the day of the inspection. The dining room was homely and the tables laid with white table linen. It was noted, however, that artwork from a craft class was pinned up around the room, this gave the room a children’s classroom feel instead of a domestic dining room. Artwork files could be set up to keep residents pictures in or framed and displayed more appropiately. A planned maintenance programme was seen but there was little evidence of this being implemented. The manager said two bedrooms had been decorated this year. Decoration was needed in many areas of the home for example woodwork in corridors was chipped and shabby. The programme of maintenance needs to be continued to ensure pleasant surroundings of a good standard are maintained. The home was generally clean, hygienic and free from unpleasant odours in most areas on the day of the inspection. Skirting boards were seen to be dirty in many areas of the building and some artificial plants, pictures and ornaments faded and dusty. It is recommended that a deep clean takes place and some accessories are upgraded. Policies and procedures were in place with regard to infection control. Staff were provided with disposable gloves. Liquid soap and paper towels were provided near hand washing facilities. Staff were observed to be maintaining good hygiene practices. The pre-inspection questionnaire noted that the environmental health and fire officer had last visited in November 05. The laundry was sited away from the food preparation area and was seen to be clean and orderly. Sufficient and suitable equipment was provided and laundry was attended to efficiently. Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. The numbers and skill mix of staff meets Service users’ needs. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of staff were provided to meet the needs of residents. The majority of staff were trained and competent to provide residents with the support they need. EVIDENCE: Clear duty rotas showed five staff on duty to meet the needs of twenty-six residents at busy times of the day. On the day of inspection sufficient care staff were on duty to meet residents care needs. The home had a visiting handyman half a day a week and one fulltime and one part time domestic. It should be considered if this is sufficient to maintain standards of repair and cleanliness around the home. 69 of the care staff had a national Vocational Qualification (NVQ) to a minimum of level two. Four staff have recently enrolled to complete NVQ 3 and two staff to complete NVQ 2. The manager is currently working towards her Registered Managers Award (RMA). Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 Page 21 Inspection of three staff files showed criminal records bureau (CRB) checks that the home had applied for were all in place for staff. No staff photographs were seen and two staff files did not have evidence of identification. This was discussed with the manager. Two written references were seen on all three flies. The health declaration on application forms is very brief and it was recommended that more detail be requested from applicants showing physical and mental fitness to undertake their role. Inspection of files showed that the home has recently implemented Skills for Care workbooks for staff to complete as part of their induction. Staff interviewed said they had shadowed other experience workers until they felt confident enough to work alone. Training records were in place. These showed training had taken place since the last inspection in, Infection control Health and safety First aid Medication management Moving and handling Fire safety. One member of staff interviewed confirmed he had received training in dementia care but records showed this is an area of training that needs to be undertaken by all staff. Staff said “I love my job” “ we work as a team” and “I feel I could take on more responsibility.” Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Quality assurance systems were in place but not used often enough to allow residents to voice their opinions Regular supervision for staff would enable staff to improve their skills supporting residents. EVIDENCE: The registered manager has many years experience in a management capacity within a care home setting. She is currently working towards her registered Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 Page 23 managers award (RMA) and plans to start NVQ 4 in care on completion of her RMA. Regulation 26 visits that audit the quality of the service were not logged on the homes file since August 2006, this does not mean these have not happened but the reports should be sent from the main office to the home following each monthly visit. An internal quality audit was seen dated 2005. This included surveys with residents and their relatives and showed an action plan from the results of the survey. There was no evidence that this exercise had been repeated. One residents meeting was held over the last twelve months it was discussed with the manager that these should be held more often. Staff meetings were held but only two had been recorded in the last year. Staff meetings should be held a minimum of six times a year. The management of resident’s finances was generally undertaken by their families or designated representatives. Only personal allowances are held for any purchases made and receipts are given to their relatives. Money held was found to correspond to the log. A supervision schedule was in place. The manager said the aim was to hold six supervisions per year, currently only an average of two per year were being held and no staff were receiving annual appraisals. It was discussed with the manager that the supervision of staff could be shared amongst the management team. The home had a health and safety policy. Regular weekly checking and testing of the fire detection system, fire exits was undertaken and documented. Accidents were being recorded in an accident book. These records should be filed in residents/staff files and not left in the book as they contain confidential information. The equipment and services within the home were serviced on a regular basis in accordance with the individual requirements, for example all portable electric equipment was tested in June 2006. The thermostatic control valves had been serviced but testing of water temperatures on a weekly basis and the reporting of any variation was not being done. This was discussed with the manager. Grange Lea Residential Home DS0000009287.V308215.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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 3 X 3 2 x 3 Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15(2)(a) (c)(d) Requirement The registered person must make the service users plan available to the service user. Where appropriate and, unless it is impracticable to carry out such consultation, after consultation with the service user or a representative of his revise the service users plan. Specifically residents must have their care plan made available to them and evidence kept to show they have seen this. Residents or their relatives should be involved in reviewing their plan. Timescale for action 31/01/07 2. OP12 16(2) (m)(n) The registered person must 31/01/07 consult service users about their social interests and make arrangements to enable them to engage in local, social and community activities. Consult service users about the programme of activities arranged by or on behalf of the care home and provide facilities for recreation, fitness and training. Specifically an activities plan must be developed in DS0000009287.V308215.R01.S.doc Version 5.2 Page 26 Grange Lea Residential Home consultation and a copy sent to the CSCI. 3. OP29 19(5)(c) The registered person shall 31/01/07 ensure staff are physically and mentally fit for the purpose of the work, which he is to perform at the care home. Specifically evidence of fitness as part of the recruitment process must be in more detail and photographs of staff held on their files. The registered person must 31/01/07 ensure the complaints procedure shall be appropriate to the needs of service users. Specifically the complaint procedure should be in a format that could be understood by everyone for example in large print with symbols and photographs. The registered person must ensure the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally and all parts of the care home are kept clean and reasonably decorated. Specifically a maintenance programme must ensure decoration and cleaning takes place. 31/01/07 4. OP16 22(2) 5. OP19 23(20(b) (d) 6. OP33 26(1) The registered provider shall visit 31/12/06 the care home in accordance with this regulation and prepare a written report on the conduct of the care home and supply a copy to the registered manager. Specifically visit the care home monthly and forward a report to the manager. The registered person shall DS0000009287.V308215.R01.S.doc 7. OP33 24(1)(3) 31/01/07 Version 5.2 Page 27 Grange Lea Residential Home establish and maintain a system for consultation with service users and their representatives. Specifically ask relatives views on the service provided- for example annual surveys. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations The registered person should ensure loose notes on assessments are removed and information added to the assessment The registered person should ensure artwork in the dining room is displayed in a more appropriate manner. The registered person should consider if an appropriate amount of domestic/handyperson hours are provided at the home. The registered person should consider adding to care plans life history, hobbies and interests. The registered person should ensure staff receive supervision six times per year 2 3 OP12 OP27 4 5 OP7 OP36 Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Grange Lea Residential Home DS0000009287.V308215.R01.S.doc Version 5.2 Page 29 - 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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