Inspection on 31/10/05 for Granville House

This inspection was carried out on 31st October 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

Granville House 08/04/08

Granville House 16/04/07

Granville House 26/06/06

Granville House 16/05/05

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 Granville House 4 Moultrie Road Rugby Warwickshire CV21 3BD Lead Inspector Deborah Shelton Unannounced Inspection 31st October 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Granville House Address Granville House 4 Moultrie Road Rugby Warwickshire CV21 3BD 01788 568873 01788 550574 trustedcareltd@Aol.com 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) Trusted Care Ltd Miss Rita Maija Plume Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registration is for 17 places in the category of old age, not falling within any other category. 16th May 2005 Date of last inspection 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. 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 DS0000060619.V261447.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The following are the findings of an unannounced inspection visit that took place between the hours of 10.00am and 6.00pm on Monday 31 October 2005. During this inspection the Manager was on duty along with two care staff a domestic and the owners wife who was working in the kitchen. Fourteen people were living at Granville House, seven were spoken to about their experiences of life at the Home. The inspection process also involved looking at paperwork, a tour of some areas of the building and discussions with the owner and with the staff on duty. What the service does well: What has improved since the last inspection? The manager has introduced a supervision system and has ensured that all staff receive regular supervision. The close working relationship between the manager, owners and staff ensures that levels of communication are good. Induction training has started for the new staff member using the TOPSS format. Induction training for this member of staff is ongoing. Care staff have vastly improved the content and quality of information recorded in daily entries. These now record what residents are doing on a daily basis and whether staff have provided any personal or health care. Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 6 A record book is now being used to record activities undertaken by residents, this book records the name of the resident and the activity they have done. Some improvements are still required to ensure that documentation is kept up to date and evidence is available that residents are involved in the type of activities available. The new care planning system has now been fully implemented. The manager must now ensure that all residents or their representatives are involved in the care planning process including monthly reviews of care plan goals. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3. Standard 6 is not applicable The Home is unable to demonstrate that all residents have agreed to the terms and conditions of occupancy at Granville House. Resident’s needs are fully assessed before admission enabling a plan of care to be developed to meet their individual needs. EVIDENCE: Currently none of the residents have agreed and signed a contract/terms and conditions of occupancy. A new contract was developed following the last inspection of the Home. The manager has not given a copy of this document to residents. The manager visits people who have said that they may like to move in to Granville House. A comprehensive assessment of prospective resident’s needs is undertaken before their admission. This assessment includes details regarding health, personal and social care. The assessment process ensures that Granville House has the facilities and staffing to meet the needs of the potential resident and enables staff to generate a care plan to meet individual needs. Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 Care plans provide staff with the information they need to meet residents’ health care needs. Residents also have good access to a wide range of health professionals which results in their healthcare needs being met. Not all medicines are being stored and details recorded appropriately which is unsafe and could result in a risk of harm to residents. EVIDENCE: The manager has worked hard to introduce a new system of care planning. Each care file now contains a pressure sore risk assessment (Waterlow), dependency score, moving and handling assessment, short term care needs assessment and long term care plan goals. Nutritional risk assessments are not undertaken although the manager is now weighing residents on a fairly regular basis. Three care files were reviewed, some information recorded was brief and requires expanding. Information is not recorded to show whether assistance is required with oral hygiene. Discussions with the manager demonstrated that she clearly knows the needs of residents, the manager stated that staff are also fully aware of care needs. Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 10 Not all care plans have been signed by the resident or their relative to demonstrate that they are involved in the care planning process. Two residents were asked if they had seen their care plans and they said that they had not. The manager has photographs of all residents but has yet to put these on care files to assist staff with identification of residents. Staff are now including more detail in daily entries, those seen recorded information about how a resident had spent their day and how staff had met their care needs. A separate file is kept to record details of visits by the GP, Optician, Chiropodist and District Nurse. Some of the residents spoken to were well aware of their health care needs and confirmed that staff are good at contacting the GP and District Nurse whenever they need to. At the last inspection of the Home one medication was not being stored appropriately as a controlled drug. The manager has obtained advice and is storing the medication according to this advice. The latest edition of the British National Formulary requires that this medication is stored as a controlled drug. This drug is currently not being stored appropriately and details regarding administration are not being recorded in a controlled drug register. Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15 Social/leisure activities do not meet the expectations of all residents although opportunities to participate in activities are improving. Residents are able to receive visits from family and friends and staff ensure that visitors are made welcome. This improves resident’s sense of wellbeing. There was limited evidence to demonstrate that residents are able to exercise choices regarding meals and social/leisure activities this could result in poor self-esteem. There is no choice of meals on a daily basis, however, menus demonstrate that meals are wholesome and nutritious. EVIDENCE: There is no programme of planned activity, the manager stated that she prefers to speak to residents on a daily basis and give them a choice. Details of any activities that take place are now being recorded in a book. Manicures, hairdressing, dominoes are undertaken on an ad hoc basis and details are recorded in this book. The manager stated that other activities take place such as visits to local shops, walks in the garden or the street, visits by family or friends but these are not always recorded. An hour is set aside most days to try and spend one to one time with residents. Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 12 Staff sit and chat to residents, do manicures or help them to play games. Three of the seven people spoken to said that they sometimes get bored. Two of the residents sitting in the lounge were chatting, others were sleeping or watching the television. The owners wife spent time in the afternoon chatting to residents in the lounge about a recent holiday she had taken and they appeared to enjoy this. Four comment cards were completed by residents and forwarded to the Commission for Social Care Inspection. Comment cards ask ten questions about life at the Home, one of these questions relates to activities. Three residents have responded saying that suitable activities are provided, one has responded saying that suitable activities are only sometimes provided. Details of likes and dislikes regarding food, reading, TV are recorded in care files. There is no documentary evidence to demonstrate that residents have had a say in the type of activities that are available. During the afternoon of the inspection one resident was having her nails manicured another lady showed the inspector her nails and said that she enjoyed having them done. Staff were seen to be patient and kind. Residents are able to see visitors in their own bedroom or in any of the communal areas of the Home. They confirmed that visitors are made to feel welcome and offered refreshments. During the visit the manager demonstrated that she had a good relationship with visitors to the Home. Visitors called in to the manager’s office to say hello and chat about their relative. None of the residents use advocacy services, contact details are available should anyone require them. A menu is on display on the notice board outside the kitchen. Residents are not given a choice of meals. During discussions the manager and the owners wife demonstrated their knowledge of individual residents likes and dislikes. Slight changes are apparently made to the menu to accommodate likes and dislikes. There is no documentary evidence to demonstrate this. All residents spoken to said that the food is good a majority of the time. Two residents commented that if they don’t like the meal they don’t eat it, they were unable to confirm whether they were offered an alternative. Vegetarian meals and curries are provided for the Asian residents. Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Adult protection arrangements in place do not protect residents from harm and need further development. EVIDENCE: There have been no allegations of abuse at this Home. One member of staff spoken to regarding abuse stated that she would report any act of abuse that she witnessed directly to the manager or the owner, she was unsure of any other action that she should take. Staff are enrolled on a training course regarding adult protection which starts in January 2006. Those staff that have completed NVQ level 2 training have already done some training regarding adult protection. A policy is available which states that staff are not to accept gifts from residents or visitors and that they are not to witness or benefit from any residents will. The Home’s adult protection procedure is brief and does not contain enough information to guide staff should abuse be suspected. The whistle blowing policy does not contain relevant information. The policy relates to confidentiality and no details regarding staff being able to inform management of any malpractice or mistakes that occur during the working day. Staff should be encouraged to raise concerns regarding poor working practice. Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 14 Six care staff are employed, five of whom have criminal records bureau (CRB) checks undertaken. The CRB check for the new member of staff has been sent off in the post and the manager is awaiting the reply. Duty rotas demonstrate that this member of staff works mainly shifts in the day where she is supervised by other staff members. The manager confirmed that any night shifts that she was due to work will be covered by another staff member until her CRB check is received. Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 The appearance of this Home created a comfortable and homely environment for the people living there. Some improvement is necessary to the environment to ensure that infection control can be managed more effectively. The current method of cleaning commodes presents a risk of cross infection for staff and residents. Lack of lockable doors and lockable facilities in bedrooms does not give residents the option of restricting access to other residents should they wish to do so. EVIDENCE: Granville House is not a purpose built care home but has been adapted to meet the needs of elderly residents. The Home is located in a residential area close to the centre of Rugby. Adaptations are in place to assist those with mobility difficulties. Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 16 The rear garden was reasonably well maintained, the owner was on the premises at the time of the visit doing gardening. Tables and chairs are available for those who wish to sit out in the garden. Three residents were spoken to in their bedrooms, these rooms had been personalised with items such as pictures and ornaments. Rooms were clean and tidy and free of offensive odours. One resident said that his bedroom was going to be re-decorated and he had chosen the colour for the paint. All spoken to said that their rooms are always tidy and clean. Residents do not have a piece of lockable furniture in their bedrooms to store personal items. Bedroom doors are not lockable. The manager feels that a majority of those that live at this Home would not be capable of looking after a key. There was no risk assessment to demonstrate that this is the case. There is no risk of burns or scalds to residents from hot water outlets or hot surfaces. Radiator covers are on all radiators and thermostatic mixing valves have been fitted to hot water outlets. The manager monitors the temperature of hot water on a monthly basis. The laundry was orderly with no backlog of items to be laundered. The sluice sink has yet to be fitted in the laundry area, this was identified at the last inspection of the Home. Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 30 Residents benefit from enthusiastic staff that work positively to improve their quality of life. The number of staff is sufficient to meet the care needs of those living at the Home. EVIDENCE: Three week’s duty rotas were reviewed. These rotas demonstrated that there are sufficient staff on duty to meet the care needs of those who live at Granville House. Rotas show that Monday to Friday the manager plus two care staff are on duty until 6pm and then two care staff are on duty until 10pm. There is one waking and one sleep over staff member. At the weekend three staff are on duty between 8am – 10pm and then one waking staff member and one sleep over until 8am the next morning. One domestic is employed for 15 hours per week. The owners wife cooks meals on a daily basis and undertakes care duties in the afternoon. Staff were seen to be attentive to residents needs, they were patient and caring. Residents spoken to said that staff are always busy, they come to you when you call for assistance and are happy in their work. One staff member spoken to said that communication between staff and management at this Home is excellent, she felt that everyone worked well as a team and help each other out. The staff member said that the manager’s main priority is the residents and they are told to spend time each day chatting to residents and making sure that everything is alright. Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 36, 37 and 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. Appropriate systems are in place to safeguard residents financial interests. Staff are appropriately supervised to ensure that they have the support, skills and knowledge to met residents’ needs. Not all health and safety issues have been addressed to ensure that residents live in a safe environment. EVIDENCE: The manager forwarded a satisfaction survey to residents in October 2004. No further survey has been undertaken since that date. Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 19 There was no documentary evidence available to demonstrate that any method of quality assuring the systems and practices in operation at the Home takes place. Residents spoken to were complimentary about the staff and the food although some said that they did not always eat their meals if they did not like what was on offer and that there was no choice. Comments regarding lack of activities were noted verbally from three residents and in the results of one quality assurance questionnaire viewed. Policies and procedures have not been reviewed recently. Some policies seen on the day of inspection did not contain sufficient detail and another contained incorrect information. Residents are able to maintain their own financial affairs if they wish. Relatives are responsible for resident’s finances in a majority of cases at Granville house. Written records are kept of any financial transactions that take place. Records were kept in a satisfactory manner, receipts are kept for any expenditure. The manager has undertaken supervision sessions with staff and is on course for meeting the requirement to undertake six supervision sessions per year. Only one care plan has been signed by the relevant resident. The manager confirmed that care files are available to residents should they wish to review them, however there was no documentary evidence to confirm this. The owner must complete some works to cover electrical wiring by the boiler, there is no landlord’s gas safety certificate available. Portable appliance testing is still to be undertaken, this was a requirement of the last inspection. Window restrictor devices are not fitted on any windows currently. The manager reported that new windows are to be fitted in the near future, this issue will be addressed when the new windows are fitted. Records demonstrated that regular servicing of fire fighting equipment takes place as well as appropriate in house checks and fire drills. During the inspection a member of staff was seen moving a resident in a wheelchair without footplates. This is considered to be unsafe practice. Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 20 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 X 2 3 X X N/A 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 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 3 X X X X 2 X 2 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 3 2 2 Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes 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. (Outstanding since 5 October 04) 2. OP7 15(1)(2)( a)(c)(d) Care Plans must be signed by Service Users or their representatives upon implementation and review to demonstrate their involvement and agreement to care prescribed. (Outstanding since 16 May 05) 19/12/05 Timescale for action 19/12/05 Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 22 3. OP8 14, 17(1) Sch 3 Nutritional screening must be undertaken upon admission to the Home and subsequently on a periodic basis. A record should be maintained of nutrition. (Outstanding since 16 May 05) Records must be available to demonstrate needs regarding oral hygiene and the action staff are to take to meet these needs. 16/01/06 4. OP9 13(2)17(1 a3 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. (Outstanding since 16 May 05) 30/11/05 5 OP12 16(2)(m) (n) An activity programme must be 30/01/06 developed following consultation with the residents about their social and leisure interests Activity programmes must be available 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. Documentary evidence must be 30/01/06 available to demonstrate choices made by residents i.e. Minutes of Residents meetings, discussions regarding activities, menu development, choices regarding locks on bedroom doors. 6 OP14 16(2)(m) (n) Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 23 7. OP15 16(2)(m) (n) Details of any variation to the Homes menu must be available for review. (Outstanding since 16 May 05) 30/01/06 8 OP18 12(1) The Home’s adult protection policy must contain sufficient information to enable staff to act appropriately should abuse be suspected. The whistle blowing policy should contain information guiding staff on the steps to take to report malpractice or concerns. 19/12/05 9 OP18 12(1) 13(6) All staff must have an up to date 30/11/05 criminal records bureau check. The manager must ensure that a Pova or Pova first check is also undertaken on all staff. The staff member currently employed without the CRB check must work under supervision of existing employees. Documentary evidence that a POVA first check has been undertaken must be provided with the action plan of this report. 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. (Outstanding since 16 May 05) 30/01/06 10. OP24 16(1)(2)1 2(4)(a) Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 24 11. OP26 13(3)16(2 (j) A sluice facility must be installed to ensure good infection control practices. (Outstanding since 27 April 04) 16/01/06 12 OP33 24(1)(a) (b)(2)(3) The registered person must 30/01/06 introduce a system of clinical and management information audits as part of the quality system for the home. (Outstanding since 5 October 04) 13. OP37 24(1)(a) (b)(2)(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. (Outstanding since 16 May 05) 16/01/06 14. OP38 13(3)(4)a -c(6) Documentary evidence must be available to demonstrate that Portable Electrical Appliance testing is undertaken on a regular basis. An up to date Landlords Gas Safety Certificate must be available for review (Outstanding since 16 May 05) The manager must ensure that staff are trained to move and handle residents appropriately and that unsafe practices are stopped. 19/12/05 Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 25 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 OP15 OP16 OP33 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 service user survey with service users and relatives. The registered manager should produce an action plan from the survey results to move forward and ensure a quality service is delivered. Granville House DS0000060619.V261447.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Leamington Spa Office 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 DS0000060619.V261447.R01.S.doc Version 5.0 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!