Inspection on 16/05/05 for Granville House

This inspection was carried out on 16th May 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 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

Granville House 08/04/08

Granville House 16/04/07

Granville House 26/06/06

Granville House 31/10/05

Granville House 05/10/04

Granville House 05/05/04

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

CARE HOMES FOR OLDER PEOPLE Granville House 4 Moultrie Road Rugby Warwickshire CV21 3BD Lead Inspector Deborah Shelton Unannounced 16 May 2005 10:00 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. Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Granville House Address 4 Moultrie Road Rugby Warwickshire CV21 3BD 01788 568873 01788 550574 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) Trusted Care Ltd Miss Rita Maija Plume PC 17 Category(ies) of OP 17 registration, with number of places Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The registration is for 17 places in the category of old age, not falling within any other category. Date of last inspection 05 October 2004 Brief Description of the Service: Granville House provides personal care for 17 older people aged 65 years and over. It does not provide any specialist services or nursing care. The providers are hands on in the running of the home. The care staff are very experienced. Several are from overseas, with a wealth of experience in caring for older persons. Granville House is a converted domestic dwelling, extended to the rear. It is situated approx 1/2 a mile from the town centre of Rugby, The Home is sited on the corner of Moultrie and Elsee road opposite Lawrence Sheriff School. Shops, buses and main town are within a short walk of the home. Accommodation is over two floors. There are 13 single rooms and 2 shared. No en-suite rooms are available. A passenger lift enables access to both floors and is large enough to take a wheelchair. The gardens to the front and rear of the house are well tended. A large conservatory is available to the rear of the building. Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 10.25 hours and was unannounced. This was the first statutory unannounced inspection visit for the 2005/06 inspection year. A tour of the premises took place and discussions were held with three residents, the manager, the owner and two visitors. Their comments are included in this report. On the day of the inspection there were thirteen people living at Granville House and a further two in hospital. The manager, the owner’s wife and two other care assistants were on duty. The owner attended for part of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Statements of terms and conditions of occupancy must be available for social services funded residents. Currently these are not available. Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 Page 6 Details of service users previous leisure interests are recorded in care files. However there is no documented activity programme in place to meet the individual needs of residents. Residents should be consulted about activity programmes. There has been no progress in meeting requirements made at previous inspections regarding quality assurance systems. There are also some improvements to be made to record keeping, induction of new staff and staff supervision. Bedroom doors do not have locks in order to maintain the privacy of residents. 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. Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 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 standard(s) 2, 3, 4 There is a pre-admission assessment prior to residents moving into the Home. Assessment and Care Management Care plans along with the Home’s pre-admission assessment form the basis to assure that care needs can be met. EVIDENCE: There was no evidence available to demonstrate that each service user is provided with a contract/statement of terms and conditions of occupancy upon moving in to the Home. The manager reported that privately funded residents have a contract. This document was not available as it was being amended. There is no statement of terms and conditions of occupancy for social services funded residents. (A copy of the Home’s contact was forwarded to the Commission for Social Care Inspection following the inspection). The manager visits people who have expressed an interest in moving in to Granville House. During this meeting discussions are held regarding the facilities available at the home and a pre-admission assessment is undertaken. Assessments ensure that Granville House will be able to meet the potential residents’ needs. Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 Page 9 Newly developed pre-admission documentation was available. One or two areas as detailed in standard 3.3 were missing from the assessment form. These areas are included on initial care plans. The manager reported that only one service user has been admitted to the Home since this from has been developed. This service user has passed away and all documentation has been archived. There was therefore no documentary evidence to demonstrate that the pre-admission documentation has been used. Assessment and Care Management Team Care Plans were available as necessary. The Home does not provide specialist services for people with dementia, physical disabilities etc. Specialist equipment such as mattresses and other equipment to prevent pressure damage is provided by the District Nursing service. Staff training is ongoing, the current staff group has received the training to meet the needs of the residents at Granville House. Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 The staff have a very good understanding of the service users’ support needs. This is evident from the positive relationships that have been formed between staff and service users. EVIDENCE: Three care files were reviewed and discussions were held with these residents to obtain their views about life at Granville House. Staffing, delivery of care, facilities and social and leisure aspects were discussed. A new system of care planning has recently been started. Two of the files looked at were overdue for review by the manager. The manager is aware that care plans must be reviewed on a monthly basis. Service users had not signed their care plans to demonstrate their involvement in the care planning process. Care plans contained a lot of information to enable staff to be able to meet the care needs of individuals who live at Granville House. A majority of daily entries were informative, a small few were brief and did not contain sufficient information “i.e. … is fine”, this does not give any detail of care given or how the resident has spent their day. Night reports were also brief and not all recorded if checks had been completed during the night. Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 Page 11 Additional information has been included in care plans regarding night routines. This was a requirement of the last inspection. Staff were seen carrying out care plan objectives. Staff treated residents with respect, were patient and caring. The old care planning system contained photographs of residents, the manager has only just finished transferring information to the new system and is aware of the need to transfer the photographs to the new files. The three residents spoken to all said that their health and personal care needs are met. Details of optical, dental and chiropody visits are recorded in care files. Each resident sees an NHS chiropodist every four months. Residents spoken to confirmed that they see their GP whenever they need to and have regular dental, optical and chiropody checks. Risk assessments are undertaken to identify those residents at risk of developing pressure areas. There is currently no one at the Home who has a pressure area. There was no care plan for one resident who was assessed as at high risk of developing a pressure area. The manager discussed the action that staff take to ensure those at high risk do not develop sores. Activities undertaken are recorded in daily entries there is no activity programme. The main types of activity undertaken are going for a walk, board games and manicure. A member of staff was manicuring resident’s nails at the start of the inspection. Residents were chatting and seemed to be enjoying the experience. Nutritional screening does not take place. The weight of a resident is only recorded if the manager feels that someone has gained or lost weight. It was a requirement of the last inspection that care staff must receive appropriate training to meet specialist needs of residents, also that the psychological health of residents must be monitored. One resident spoken to stated that he sometimes get depressed but staff are very aware of his changing moods and spend extra time talking to him and call his GP as necessary. A community psychiatric nurse (CPN) visited Granville House to talk to staff about depression and mental health issues. The manager reported that CPNs are contacted for advice as needed. A further training session is to be held in the near future. Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 Page 12 One medication currently in use is not being treated as a controlled medication” the manager is ensuring staff double sign medication administration records (MAR sheets) for this medication. There is no controlled drugs register and this medication is not being stored as a controlled drug. The pharmacist visits the Home on a weekly basis to bring medications. The pharmacist regularly reviews policies and procedures and storage of medication. Homely remedies are not available. The manager reported that residents are taken to see their GP if they require any medication. No service user selfadministers medication. All staff that administer medication had undertaken an accredited training course regarding medication handling, administration and storage. The lunchtime medication round was observed. The staff member was administering the medication safely according to the Home’s policy. Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 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, 15 There was no documentary evidence to demonstrate that service users views are sought or acted upon. As a result there are only limited types of activities being undertaken on a regular basis. EVIDENCE: There is no activity programme in place. Activities are discussed on a one to one basis. The manager said that an hour is put aside each morning to do manicures, take people for a walk, and play board games. Other activities are then undertaken as staff are available. On the day of inspection both ladies and gentlemen in the lounge were having a manicure. The staff member was chatting to residents about issues of general interest. Residents appeared to be enjoying the experience. Formal resident meetings do not take place. Choices are given to residents informally by chatting on a one to one basis. Three service users spoken to said that they have a choice in everything that they do and they confirmed that choices are given to them when they talk to staff. Details regarding likes and dislikes, routines and religious needs are recorded in care plans. Brief details are also recorded regarding previous leisure and social activities undertaken before moving in to the Home. Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 Page 14 Those seated in the lounge were asking staff what was for dinner, what were the accompanying vegetables and what was for desert. The staff member told the residents what was available for the main meal and gave the option of an alternative if they did not want this. Service users were seen to be given a choice about where they ate their lunchtime meal. All were encouraged to go in to the lounge as it is felt that it can be a social occasion. One lady requested her lunch on a tray in the dining room. Staff accommodated her wishes and made sure that she had salt and pepper and a cold drink. This meal was well presented and appetising and the service user appeared to enjoy the food. During discussions with the manager it was evident that she was fully aware of the likes and dislikes of those who live at Granville House. There is no documented choice of main meal on the menu but the manager stated that a choice is verbally given if a service user says that they do not want what is available. The three service users spoken to confirmed this. All spoken to said that the food is good and that they would tell staff if they didn’t want what was being offered. They also stated that they are always bought an alternative meal of their choice. There is no documentary evidence to demonstrate that alternative meals are provided. It was a requirement of the last inspection that residents are involved in menu development. There was no evidence to demonstrate that this has been actioned. Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 The Home has a satisfactory complaints system with some evidence that service users feel that their views are listened to and acted upon. EVIDENCE: No complaints have been received by the Home or the Commission for Social Care Inspection since the last inspection. A copy of the complaint procedure is on display at the Home. This gives the contact details for the Commission for Social Care Inspection should anyone wish to contact them direct. It was a requirement of the last inspection that appropriate timescales be included in the complaints policy, this issue has been addressed. All residents spoken to said that they would be happy to talk to the manager if they had any problems and they felt that she would address the problem straight away. The owner and his wife are on the premises most days, they also said that they are happy to deal with any concerns. The manager discussed the system for recording and monitoring complaints. Details of concerns would be recorded and the resident would be requested to sign the form showing their agreement to the concerns and the action to be taken to investigate. Once concluded details of the investigation and outcome are recorded. Details are kept on individual care files. There is no complaints folder that holds details of all complaints received. Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 Page 16 All service users were given the option of voting at the last elections. A majority preferred to complete postal votes and one gentleman was taken to a local polling station. Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 Page 17 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) 21, 24, 25, 26 The standard of the environment within this Home is good providing residents with an attractive and homely place to live. EVIDENCE: Three toilets are available on the ground floor and three on the first floor. These are located close to lounges, bedrooms and dining rooms for ease of access for residents. Ensuite facilities are not available. An assisted bath is located in the ground floor bathroom and an assisted shower in the first floor bathroom. Bedrooms viewed had been personalised with pictures and ornaments and were in a reasonable state of décor. Rooms were warm and bright. An unpleasant odour was noted in one room. The manager was aware of this and is tying various actions to remove the odour. All other bedrooms were clean, hygienic and free of odour. Lockable facilities are not available unless requested by a resident. Not all bedroom doors are lockable. Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 Page 18 All radiators are housed in protective covers to remove any risk of burns to residents. A risk assessment of hot water temperatures resulted in thermostatic mixing valves being fitted. Hot water temperatures are taken on a monthly basis and records demonstrated that temperatures are all under the maximum therefore removing the risk of scalding. The room number was not recorded showing where the water temperature had been monitored. Samples of water are sent on an annual basis to assess for legionella bacteria. Results have been satisfactory. The laundry was clean and orderly with no backlog of items to be laundered. The owner confirmed that a sluicing facility is being fitted within the next month in the laundry area. All equipment in the laundry was in good working order. Washing machines have the programming ability to meet disinfection standards. Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 Page 19 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) 28, 29, 30 The management of staffing issues such as recruitment and training ensure that a skilled and motivated workforce meet the needs of service users at this Home. EVIDENCE: Ten staff are employed, nine of these have obtained NVQ level two. Agency staff are not used to cover shifts residents therefore receive care from the same staff on a regular basis. The manager confirmed that work has been undertaken to bring staff files up to date since the last inspection. Three files were reviewed and all contained sufficient information in order to meet standards i.e. application forms, references, criminal records bureau checks, copies of passports etc. The manager is in the process of obtaining information regarding TOPSS induction and foundation training. A copy of the TOPSS “Managers Guide to Induction Training” has been obtained. This will be implemented when further information regarding induction of care staff has been obtained. This was a requirement of the last inspection. Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 38 There is no system in place to ensure that the quality of the service provided meets the needs and expectations of the Service users who live at the Home. Management and administration practices do not ensure that the health and safety of service users and staff are maintained. EVIDENCE: A letter was sent in October 2004 to residents and their families asking for comments about Granville House. All comments received were positive. The results of this survey have not been collated. The views of other stakeholders such as GP, Optician, hairdresser etc have not been requested. Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 Page 21 The manager has an excellent relationship with residents and their families and talks to them on a daily basis. The residents and the visitors spoken to confirmed this. The manager feels that this is an excellent way of obtaining both positive and negative feedback. There is no formal system in place for measuring the quality of care provided at Granville House. This was a requirement of the last inspection. The owner does not complete regulation 26 reports. Policies and procedures are in need of updating. Formal supervision sessions have taken place but not six times per year as required. The manager stated that informal supervision takes place every day as she works closely with staff observing and discussing care practices. Individual care records are kept securely in the manager’s office. Various records were reviewed to assess health and safety practices at Granville House. Portable Electrical Appliances records were available, however there was no documentary evidence of a recent test being undertaken. There was no Landlord’s Gas Safety Certificate available. Documentation reviewed recorded that the boiler had been fitted incorrectly. The manager reported that this had been rectified. The manager was unable to find documentation to confirm this. A majority of staff have undertaken training such as moving and handling, fire, first aid, and food hygiene. Records demonstrated that fire extinguishers, emergency lighting and the fire alarm systems are all checked and serviced on a regular basis. Currently fire drills are being undertaken on a monthly basis. The fire officer has advised that these need to be done six monthly. Window restrictors are not in place. The manager reported that windows are being replaced. Residents will be asked individually if they want restrictors on their window when the new window is fitted. Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 2 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION x x 3 x x 2 3 2 STAFFING Standard No Score 27 x 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x x x 2 x x 2 2 2 Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 Page 23 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 OP2 Regulation 5(1)(b) Requirement Each resident must be provided with a contract/statement of terms and conditions of occupancy. The terms and conditions need to include all the information described in standard two of the Care Homes for Older Persons - National Minimum Standards. (Note - a copy of the Homes contract was forwarded following the inspection. Further work must be completed on this document to meet standards) (Outstanding since 5 October 04) 2. OP3 14(1)(a) Pre-admission assessment documentation must be available for all newly admitted residents and must contain all information as detailed in standard 3.3 Care Plans must be signed by Service Users or their representatives upon implementation and review to demonstrate their involvement and agreement to care prescribed. 05.09.05 Timescale for action 05.09.05 3. OP7 15(1)(2) (a)(c)(d) 05.09.05 Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 Page 24 Care plans must be reviewed on a monthly basis and updated as required. Daily entries must contain sufficient detail to demonstrate how a resident has spent their day and details of any care interventions given. 4. OP8 14(1)(a)( 2)(a)(b) 17(1)(a) Schedule 3 13(2) 17(1)(a) Schedule 3 Nutritional screening must be undertaken upon admission to the Home and subsequently on a periodic basis. A record should be maintained of nutrition including weight gain or loss. All controlled medications in use at the Home must be stored in accordance with the Misuse of Drugs (Safe Custody) Regulation 1973. A separate record must be kept of controlled drugs receipt, administration and disposal. These records must be kept in a bound book or register with numbered pages. 29.08.05 5. OP9 29.08.05 6. OP12 16(2)(m) (n) 05.09.05 An activity programme must be developed following consultation with the residents about their social and leisure interests Activitity programmes must be avaialble for review and evidence must also be available to demonstrate that activities take place which are suited to the wants and needs of Service Users. Records must be in place to confirm which Service Users have participated in activities and when. Minutes of Service User meetings must be available for review. Details of any variation to the Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 Page 25 Homes menu must be available for review. 7. OP24 16(1)(2) 12(4)(a) Bedroom doors must have the facility to be locked if this is the wish of the resident. Locks must be of the type that the resident can exit from the inside without the use of a key. A lockable facility must be available in each bedroom. 8. OP26 13(3) 16(2)(j) A sluice facility must be installed to ensure good infection control practices. (Note - a sluice has been purchased and the owner confirmed that this will be installed within the next month). (Outstanding since 27 April 04) Work must be undertaken to remove the slight odour in one service user’s bedroom. 9. OP30 18(1)(a) (c)(i) 29.08.05 The registered manage must send a copy of the induction training programme based on National Training Organisation standards to Commission for Social Care Inspection within one month of this inspection. (Note - the manager has obtained some documentation but has yet to implement any induction training). (Outstanding since 5 October 04) 10. OP33 24(1)(a) (b)(2)(3) The registered person must 05.09.05 introduce a system of clinical and management information audits as part of the quality system for the home. Version 1.30 Page 26 19.09.05 19.09.05 Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc (Outstanding since 5 October 04) Regulation 26 visits must be undertaken on a monthly basis and a copy of the report forwarded to the Commission for Social Care Inspection. 11. OP36 18(2) The Registered Manager must ensure that all staff receive supervision at least six times a year. Supervision must cover the topics detailed in standard 36.3. Policies and procedures must be updated to include information relevant to the Home, they must have implementation dates recorded and have regular reviews of their contents, the dates of reviews must also be noted on policies. Documentary evidence must be available to demonstrate that Portable Electrical Applicance testing is undertaken on a regular basis. An up to date Landlords Gas Safety Certificate must be avaiable for review 29.08.05 12. OP37 24(1)(a) (b)(2)(3) 05.09.05 13. OP38 13(3)(4)( a)(b)(c)(6 ) 05.09.05 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. 3. Refer to Standard OP15 OP16 OP33 Good Practice Recommendations The registered manager should include service users in menu development. The registered manager should devise a complaints folder to store details of any complaints received. The registered manager should share the results of the E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 Page 27 Granville House service user survey with service users and relatives. 4. OP33 The registered manager should produce an action plan from the survey results to move forward and ensure a quality service is delivered. Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB 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 Granville House E53 S60619 Granville House V226218 110505 Stage 4.doc Version 1.30 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. 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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