Inspection on 10/07/07 for Grove House

This inspection was carried out on 10th July 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Grove House 09/05/06

Grove House 23/11/05

Grove House 05/07/05

Grove House 28/01/05

Grove House 23/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOMES FOR OLDER PEOPLE Grove House Moor Road Ashover Chesterfield Derbyshire S45 0AQ Lead Inspector Denise Bate Unannounced Inspection 10th July 2007 09:30 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 Grove House DS0000019999.V340904.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. Grove House DS0000019999.V340904.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grove House Address Moor Road Ashover Chesterfield Derbyshire S45 0AQ (01246) 590222 01246 590287 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) Peak Care Limited Jannine Stevens Care Home 31 Category(ies) of Learning disability (1), Old age, not falling registration, with number within any other category (30) of places Grove House DS0000019999.V340904.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 place in the category LD for service user named on proposal of conditions notice. 9th May 2006 Date of last inspection Brief Description of the Service: Grove House is a care home registered to provide care and accommodation for up to 31 older people including 1 place for a named individual with learning disabilities. The home is well established and is part of a care complex that also provides services for very sheltered housing. The home is set in its own grounds and overlooks fields and mature trees in the surrounding countryside. Amenities are available in the village of Ashover including pubs, a post office and small shops. The accommodation is a mixture of older buildings combined with a purpose built extension. There is a choice of lounges and dining rooms. 13 single bedrooms have en suite facilities, there is 1 double bedroom and the remainder are single accommodation. Car parking space is provided. Copies of the latest inspection report, statement of purpose and service user guide are available in the foyer. Current charges range from £330 to £375 per week for single rooms and up to £500 per week for double rooms used as single rooms. Grove House DS0000019999.V340904.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over six hours. During the inspection nine residents and four relatives were spoken with. A group of nine staff were spoken with. The manager was present during the inspection and provided assistance and information, and the proprietor was also available during the inspection. Prior to the inspection a number of sources of information were looked at including the home’s service record and previous inspection reports. An Annual Quality Assurance Assessment (AQAA) was completed by the manager prior to the inspection and information provided has been used in the preparation of this report. Nine resident surveys were also received and comments from residents are included in this report, as well as comments made by residents and relatives on the day of inspection. A number of records were examined including care planning documentation, accident records, staff files and medication records. Three residents were case tracked. A tour of part of the building took place and the grounds were seen. What the service does well: Grove House provides a comfortable, homely, and relaxed environment for residents. Residents and relatives spoken with made positive comments about the home and staff including; ‘care is very good’, ‘the staff are very friendly’, ‘the staff work very hard and are compassionate’, ‘I find this home a very caring community with a cheerful atmosphere’, ‘the home is well maintained’. The manager and proprietor are seen as approachable and responsive. They are committed to continually improving the service they provide. Communal areas of the home are comfortable and provide a range of areas for residents to use. The home was found to be well maintained and standards of cleanliness are high. The food was said to be ‘excellent’, a choice of meals is always offered, and meals are attractively served in a pleasant dining room. Residents can have meals served in their bedrooms if they wish. Care planning documentation is well organised, up to date, and reflects the individual needs of residents. Staff spoken to were experienced, knowledgeable, enthusiastic and committed to the welfare of residents. There is a stable staff group who work well as a team. No new staff have been employed recently. Staff supervision takes place Grove House DS0000019999.V340904.R01.S.doc Version 5.2 Page 6 and training is given a high priority. Over 50 of care staff are trained to NVQ level 2 or 3. There is a thorough system for recruiting and training new staff and appropriate checks are carried out. There is a complaints procedure, although most day to day difficulties are dealt with on an informal basis. Staff are aware of safeguarding adults issues. There is a quality assurance programme that provides clear indications of where the home is doing well and what areas could be improved still further. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Grove House DS0000019999.V340904.R01.S.doc Version 5.2 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 Grove House DS0000019999.V340904.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available to ensure residents can make an informed choice about where they live. EVIDENCE: Copies of the Statement of Purpose and the Service User Guide are available in the foyer and are given to prospective residents and their relatives. The home also make information available over the internet. All prospective residents have an assessment carried out by the manager, as well as by health or social care professionals, and copies of assessments were seen on the care planning documentation of case tracked residents. Residents Grove House DS0000019999.V340904.R01.S.doc Version 5.2 Page 9 can take advantage of a ‘trial stay’ as well as being encouraged to look around the home and have lunch. Residents and relatives spoken with indicated that they had sufficient information to make a positive decision to move to the home; ‘we looked at other places as well’. As well as the formal information documentation several people said that the home had a very good reputation locally; ‘I lived in the same village so knew of the high quality of the home’. The home does not provide intermediate care so standard 6 was not assessed. Grove House DS0000019999.V340904.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are completed and are individualised to demonstrate that residents’ health, personal and social care needs are being met. EVIDENCE: Three case tracked residents had clearly arranged care planning documentation. Items included: a photo, admission details, a long term care plan clearly identifying every aspect of resident care; short term care plans which varied from person to person and indicated how care was to be provided in detail, monthly summaries/reviews, risk assessments (moving and handling, nutrition), weight monitoring, and day to day logs. Grove House DS0000019999.V340904.R01.S.doc Version 5.2 Page 11 Care plans were resident focussed and highly individualised e.g. including food preferences, personal routines, likes and dislikes, brief personal history and cultural and spiritual needs. All care plans had ‘end of life’ plans clearly indicated. One resident uses the ‘Wanderguard’ system, and this had been risk assessed, was monitored, and was working well. The home have a detailed system of formally monitoring resident dependency levels and this was seen by the inspector. Care plans had been signed by residents, indicating that their contents had been discussed with them. The provision of high standards of care was confirmed by residents who said; ‘we are very well looked after’, ‘I couldn’t be in a better place’, ‘I am happy and content’. Several individual residents were discussed with the manager, who gave the inspector full information on how the care planning system worked. The home caters for a wide range of needs and care is provided in a highly individualised way. Some residents have physical needs and need to use a hoist with two members of staff to transfer. Other residents have confusion or dementia but care plans clearly indicated what was important to residents, e.g. one resident has poor communication skills but the care plan identifies that she can indicate how she feels through facial expression, for another resident it is particularly important to choose her own clothes and be well dressed. Some residents have strong links with the community and the care plan identifies how these are to be supported. Some residents spoken to go out on a regular basis and can walk down to the village. For each resident a second care file contains background details and copies of assessments and care plans that have been superseded. The inspector was informed that residents can have access to all their personal records and examples were given where residents had been made aware of this and had looked through their records. The inspector was informed that all residents had contracts and that copies of them were held by the administrator. Aspects of residents’ health needs and medication were clearly presented on care planning documentation and there was a record of doctors visits and visits by other health professionals. It was reported that a good relationship exists with local GPs and with District Nurses. Members of staff were observed treating residents with dignity and respect. Staff spoken to valued residents as individuals and were aware of their needs. Some residents were unable to contribute directly to the inspection process because of communication difficulties, but they were directly observed during Grove House DS0000019999.V340904.R01.S.doc Version 5.2 Page 12 the visit to see how well their needs were met by staff. Staff were observed interacting in a positive way with residents, who were relaxed and smiling. The home uses the Medidose system for medication. There is a separate medication space where medication is kept securely. Pictures of residents are kept with their medication administration records, reducing the possibility of residents being given the wrong medication. The medication records of some case tracked residents were seen and found to have been recorded correctly. The date of opening had been recorded on eye drops and creams. The fridge temperatures were being monitored appropriately. The home have access to medication information about particular drugs and their uses and side effects. There is a homely remedies policy in place, and the manager is working closely with a local GP to develop this further. A stock check is taken on medication that has been ‘refused’ and the medication disposed of appropriately. All case tracked residents had signed medication forms. No residents administer their own medication but there is an appropriate risk assessment format available if needed. All staff have had medication training. Medication is usually administered by senior staff. Other staff initially administer medication under the supervision of the manager to ensure they have understood their training. A record is kept of staff signatures and they were found to match the signatures on the MARs sheet. Grove House DS0000019999.V340904.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides suitable activities and the quality of catering is excellent which contributes to a pleasant atmosphere and the high overall levels of satisfaction for residents. EVIDENCE: There is a residents notice board that gives information about activities and the daily menus. There are two designated members of staff who take responsibility for organising activities for up to five hours a week and outings take place every fortnight. Some comments from relatives and residents made to the inspector confirmed the findings of the home’s own quality assurance questionnaire, i.e. that there should be further development of activities to provide extra stimulation and interest. A record of activities undertaken is part of the care planning documentation and was seen on care planning records for case tracked residents. Grove House DS0000019999.V340904.R01.S.doc Version 5.2 Page 14 Four relatives were visiting on the day of inspection and the inspector spoke with them. They indicated that they were made welcome at the home and that they were ‘highly satisfied with the quality of care provided’. Good communication was reported with the home, and relatives are confident they will be kept informed of any issues or problems. There is support and interaction between residents and some special friendships have formed. Several residents referred to the fact that their friendships were important and supportive. Several residents described their contacts with the local community, which included attendance at art classes, walks into the village, and outings with family and friends. Meals are served in the attractive dining room and are well presented. Residents spoken to were very positive about the standard of catering, and the choice of menus that are available; ‘we have a very good chef’, ‘the food is very good’, ‘the meals are nicely presented’, ‘I have breakfast in my bedroom every morning’, ‘excellent food’. Grove House DS0000019999.V340904.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear and accessible complaints and safeguarding adults procedures are in place to ensure residents can be confident that any issues raised would be acted on effectively and promptly. EVIDENCE: There is a complaints procedure, although most relatives and residents prefer to raise issues on a more informal basis. No complaints have been made to the home or to CSCI. Most residents and relatives were aware that there was a formal complaints procedure. Residents and relatives said that issues raised are dealt with promptly; ‘the staff can’t do enough for you’, ‘if I wasn’t satisfied I would say so and tell the social worker’, ‘I have always been listened to’. The inspector was informed that there are clear procedures for dealing with the safety of residents and safeguarding them from harm. Staff spoken to showed an awareness of safeguarding adults issues, had received appropriate training Grove House DS0000019999.V340904.R01.S.doc Version 5.2 Page 16 and were clear about their responsibilities and would pass any concerns on to their line manager. The accident book was seen and is being filled in appropriately in line with the good practice recommendation made at the last inspection. Regulation 37 notices are sent to CSCI. Grove House DS0000019999.V340904.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides residents with an attractive and homely place to live. EVIDENCE: The building has been maintained to a good standard overall. There is a rolling programme for maintenance and redecoration. There is a choice of lounges and seating areas, and a conservatory area. The home have a patio and area of garden for residents to enjoy, and residents were outside enjoying the fine weather on the day of inspection. Grove House DS0000019999.V340904.R01.S.doc Version 5.2 Page 18 Several residents liked sitting at the front of the building where they could ‘watch the world go by’. Residents spoken to were happy with their bedrooms. Approximately seven bedrooms were seen, most have en suite facilities. Bedrooms are personalised according to residents’ preferences; ‘I like my room’, ‘I enjoy spending time in my room’. Residents had been able to bring their own furniture and were able to pursue their hobbies and interests, e.g. watching television, painting, reading, listening to music. Residents can have a telephone in their bedroom if they wish. The home are in the process of making Cabled Sky TV an option for all residents. Several residents said that they really enjoyed the view from their bedrooms; most of them had extremely pleasant views of the surrounding countryside. One bathroom and some toilets were seen, and these were satisfactory. All areas of the home seen on the day of inspection were clean and free from offensive odours and residents and relatives said that standards of cleanliness within the home were good. Grove House DS0000019999.V340904.R01.S.doc Version 5.2 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 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 good. This judgement has been made using available evidence including a visit to this service. A trained and competent workforce are in place which meet the dependency needs of residents currently accommodated within the home. EVIDENCE: Staff rotas were seen and clearly identified when staff were working as carers and when they were undertaking other duties. On the day of inspection there were sufficient care staff to meet the needs of residents accommodated within the home. Some residents and relatives said that sometimes staff were very busy. Staff said that ‘every day is different’, and that some days they were busy, particularly if any residents and staff were ill. However, staff said that they worked flexibly to cover for each other and it was very rare for a shift not to be covered. As mentioned previously, the home formally monitor resident dependency levels and the manager said that extra staffing can be made available if resident dependency increases. Grove House DS0000019999.V340904.R01.S.doc Version 5.2 Page 20 There is a stable staff group and this continuity was appreciated by residents, several of whom commented on the good relationship they had with staff; ‘staff are very kind’, ‘staff will do whatever they can to help’. A group of nine staff met with the inspector. Staff spoken with were responsible, enthusiastic, competent and committed to the welfare of residents. Staff said ‘we work well together as a team’. They enjoyed their work, and were proud of the standards of care given. Their comments included: ‘the residents here get a good standard of care’, ‘residents are treated as individuals’, ‘this is a lovely place to work’, ‘people are very supportive’. The inspector was informed that all mandatory training was up to date. Further staff training is planned on an ongoing basis, which will include further dementia care training, activity training, and infection control. The home sometimes get specialists in to give information on specific needs, e.g. a psychiatrist had recently visited to give advice on working with people with anxiety problems. Over 50 of staff are trained to NVQ Level 2 or 3 and further staff are just about to start NVQ training. The home has the ‘Investors in People’ Award. Staff said that their training opportunities are good. A new member of staff confirmed that she had received induction training and also felt well supported by her colleagues. The home are in the process of completing the ‘Skills for Care’ national audit. Two staff files were seen and had evidence of CRB and POVA checks having been undertaken, copies of references and applications forms. There have been no new members of staff appointed for some time. The home have a good recruitment and selection procedure. Grove House DS0000019999.V340904.R01.S.doc Version 5.2 Page 21 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, 32, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is suitably qualified and experienced and staff demonstrate an awareness of their roles and responsibilities, thus ensuring the home is run in the best interests of residents. EVIDENCE: Residents, relatives and staff spoke positively about the manager, saying she was approachable and responsive. She is suitably qualified and experienced, having gained the Registered Managers Award NVQ Level 4. She demonstrates Grove House DS0000019999.V340904.R01.S.doc Version 5.2 Page 22 a commitment to continuous improvement. Staff say she is knowledgeable and supportive, is clear in her expectations of staff and ‘trusts us to get on with the job’. The manager said she felt there was a very good staff group at the home and that she ‘encourages staff to say what they think’. Staff said that they had ‘very good senior staff’ who were also knowledgeable and supportive. In addition the proprietor visited the home on a very regular basis and was available to provide advice and support when needed. Staff supervision takes place on a formal basis, and all staff have an annual appraisal. The proprietor visits the home most days and is well known to both residents and staff. On the day of inspection the records of Regulation 26 visits were not available at the home, although it is understood that these are taking place. The home’s quality questionnaire carried out last year indicated that residents were happy with the service they receive. All residents felt they were treated with respect and had access to privacy when they needed it, and that Grove House was managed in a responsible and well organised way. An extension of the activities programme was the main area of improvement. The home have not yet given residents and relatives formal feedback from this exercise, although their planning indicates that they intend to address the issues raised. The inspector was informed that the home has a system for managing service users’ finances which works satisfactorily. There is an administrator who deals with finances and residents’ contracting arrangements. The residents survey indicated that most people remembered receiving individual contracts. The information provided by the manager indicates that the home makes every effort to ensure safe working systems are in place and equipment maintained satisfactorily. Accident forms were seen and were found to be filled in appropriately. Grove House DS0000019999.V340904.R01.S.doc Version 5.2 Page 23 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 X 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X 3 X X 3 Grove House DS0000019999.V340904.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? no 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. Standard Regulation Requirement Timescale for action 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 OP12 OP30 OP33 OP33 Good Practice Recommendations The programme of activities should be developed and extended to provide variety and stimulation for residents. Training should be offered to staff in infection control, activities, and dementia care to further improve the quality of care provided. Regulation 26 visit records should be kept at the home to provide evidence that they are taking place. The results of the quality assurance exercise should be formally given to residents with an action plan to demonstrate that residents views on the running of the home are being acted upon. An environmental risk assessment should be done on the gravel drive immediately adjacent to the home to ensure residents comfort and safety. 5 OP38 Grove House DS0000019999.V340904.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Grove House DS0000019999.V340904.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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