Inspection on 16/06/09 for Littleport Grange

This inspection was carried out on 16th June 2009.

CQC found this care home to be providing an Poor service.

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

Littleport Grange 16/06/08

Littleport Grange 18/12/07

Littleport Grange 13/09/07

Littleport Grange 15/01/07

Littleport Grange 07/02/06

Littleport Grange 28/06/05

Littleport Grange 17/01/05

Littleport Grange 07/06/04

Littleport Grange 24/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Littleport Grange Grange Lane Ely Road Littleport Ely Cambridgeshire CB6 1HW Lead Inspector Joanne Pawson Key Unannounced Inspection 16th June 2009 10:00 DS0000024311.V375979.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Littleport Grange Address Grange Lane Ely Road Littleport Ely Cambridgeshire CB6 1HW 01353 861329 01353 862878 littleportgrange@btconnect.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) Dove Care Homes Ltd Catherine Ann Mary Doswell Care Home 75 Category(ies) of Old age, not falling within any other category registration, with number (75), Physical disability over 65 years of age of places (75) Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Old age not falling within any other category (OP) - 75 Physical Disability over 65 years of age (PD(E)) - 75 Date of last inspection Brief Description of the Service: Littleport Grange is registered as a care home with nursing for up to 75 older people. Although the home is registered with 75 beds the home has chosen to accept only 66 people, so that they may be more comfortable. Accommodation is provided in a large detached property set in attractive and well-maintained grounds on the edge of the town of Littleport. There are local amenities within walking distance and the city of Ely is a short drive away. The house is on three floors made accessible by two lifts and stairs. There are a number of lounges and dining rooms available to residents. There are 58 single and four large double bedrooms, most with en-suite facilities. There are registered nurses on duty at all times as well as day care and night care assistants, administrators, cooks, housekeepers, bed makers, laundry workers, maintenance man, gardener and full time activities co-ordinator. Fees for the home range between £487.00 and £660.00 per week, a full range of fees is available from the home upon asking. The most recent inspection report is available in the manager’s office for people at the home or relatives and visitors to the home who wish to read it. Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This was a key inspection of this service and it took place over 7 hours and 30 minutes as an unannounced visit to the premises. It was spent talking to the manager and staff working in the home, talking to people who live there and observing the interaction between them and the staff, and examining records and documents. One requirement from the last inspection has been met and one requirement (to update care plans) has not been met. There have been four further requirements and no recommendations made as a result of this inspection. Information obtained from the Annual Quality Assurance Assessment and from returned surveys was also used in this report. Eight surveys were returned from people who live at the home, and five were returned from visitors to the home and three from the staff. What the service does well: The home is a large converted building with an extension at the rear of the building and it is situated in its own grounds. There are three different lounge areas on the ground floor, plus another two on the first floor for people to use if they wish. The gardens are well maintained and provide a pleasant area for residents to use in the warmer weather. There is a choice of main meals each day and staff members stay with people who need help to eat. One resident said ‘I love the food’. When asked if anything could be improved at the home one resident said ‘I love it here, I can’t find fault’. The two activities coordinators were observed working with the residents and both treated the residents with dignity and respect. Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 6 All complaints are recorded and the appropriate action taken. The complaints policy is on display in the foyer of the home and the residents we spoke with confirmed that they would know how to make a complaint and that they felt confident it would be dealt with appropriately. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Littleport Grange DS0000024311.V375979.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 Littleport Grange DS0000024311.V375979.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home ensures that they can meet prospective residents’ needs before they move into the home. EVIDENCE: An assessment is completed before people move into the home. Further assessments are obtained from health and social care teams and provide additional information so the home is able to say whether it has the staff with the skills and experience to properly care for someone moving in. The pre-inspection documentation showed that a new assessment has been added to the pre admission tool to assess if there are any possible issues relating to the deprivation of liberties. Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 9 Littleport Grange DS0000024311.V375979.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans do not reflect the residents’ current needs and are not used by the care staff as a working document. Therefore people who use the service cannot be confident that staff have all the information they need to provide safe and effective support. EVIDENCE: Each resident has a main care plan that is kept in the nurses’ office on the ground floor and a summary of the care plan which is kept in the residents’ bedroom. We looked at the care plans for three residents’, spoke with the residents’ where possible and asked staff what they knew about the residents’ needs so that we could see if the care plans reflected the residents’ current needs. Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 11 The first main care plan had risk assessments for pressure areas, malnutrition and creams being left in the bedroom. The risk assessments had been reviewed monthly. The care plan stated intake of food and nutrition to be monitored and that the resident was to have daily milkshakes to boost their intake of calories. However there was no chart for the monitoring of either food or fluid for the resident. When asked staff stated that the resident no longer required the monitoring chart as their food and fluid intake had improved and was no longer a concern. The staff also confirmed that the resident no longer needed the daily milkshakes. A risk assessment stated ‘turn regularly’ and the care plan stated ‘turn frequently’ and then further on ‘turn every 2-4 hours’. There was a turn chart in the resident’s bedroom. However the chart had pre printed times for turning the resident. The chart was not accurate because the resident was not always turned at the exact time stated. This could lead to the residents’ not being turned as regularly as advised by the care plan and the risk of developing pressure areas. The care plan also stated that the call bell should be within easy reach at all times. On entering the resident’s room they asked us to help them with repositioning as they were uncomfortable and to help with personal care. We explained that we could not do that but that the resident should use the call bell to request assistance. The resident pushed the call bell at 12.15 but by 12.30 no staff members had come to help. We advised the resident to press the call bell again which they did. Still no care workers came to help so we found a care worker and asked them to assist the resident. We also asked them to check the call bell was working. The call bell was not working and the batteries had to be replaced. The manager stated that the call bells usually worked and that they were checked on a regular basis. (Three other call bells were checked in different areas of the home and were working). The G.P. notes showed that the resident had been prescribed cream to be applied to their scalp. When asked who usually applied the cream the care worker on shift said that the night staff normally did this when they were assisting the resident to freshen up in the morning. However she did not think that it had been done on the day of the inspection as you could tell from the appearance of their hair. The second care plan we looked at did not have all of the information the staff needed. It stated that the resident needed hoisting and that the staff must use the correct sling but did not state what size the correct sling was. This could put the person at risk. The main care plan was completely out of date and the summary of the care plan which was in the resident’s room had writing all over it which stated that the resident’s health had deteriorated so the care plan was no longer relevant. The third care plan was for a resident with diabetes. The care plan contained detailed information about the condition and informed the staff what signs they Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 12 needed to look for. The communication care plan was also good and stated ‘staff must introduce themselves and explain everything. They must establish a good rapport to promote trust and confidence’. The care plan stated that the resident had an assessment with a speech and language therapist to assess their ability to swallow fluids. The speech and language therapist had stated that when the resident had a chest infection they should have all of their drinks thickened to prevent aspiration. The daily notes for the resident showed that at the time of the inspection the resident was receiving antibiotics for a chest infection. The daily notes did not state that the resident was having their drinks thickened. We asked a member of staff working with the resident if they were aware that the resident had a chest infection and they stated that they had returned that day from holiday and noone had updated them that the resident had a chest infection. We asked the member of staff that if the resident had a chest infection was there anything they would do differently for the resident when they were offered a drink. The staff member replied that they would stay with the resident when they had a drink because they were more likely to choke when they have an infection but that they were not aware that their drinks should be thickened. The same member of staff was also not aware that the resident was diabetic. We also spoke to another carer about the resident who stated that they were not aware of the resident ever having their drinks thickened. The lack of up to date information could put the person at serious risk. At the end of the inspection when we reported this back the manager and the nurse in charge neither of them were aware that the resident should be having their drinks thickened. Failure to follow the speech and language therapist’s advice could lead to further health problems for the resident. We looked at the medication administration records and the stock of medication for the same resident. One of the tablets stated that they must be administered before food and another one stated that it must be administered after food. However this information was not on the medication administration records. We asked the nurse in charge of the medication round on the day of the inspection if all the tablets had been administered at the same time and she confirmed that they were. Not following the instructions for individual medications could affect the effectiveness of the medication. When we reported this to the manager she stated that other residents received medications at different times and that it had been an oversight for this resident. Residents’ were seen to be treated with respect for the majority of the inspection. However a maintenance man was seen knocking and going straight in to a resident’s bedroom rather than waiting to been told it was fine to enter. Three members of staff were spoken to as part of the inspection and two of them said that they don’t get time to read the care plans and one said that he sometimes read them. Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 13 When asked how they would know what the needs of a new resident were one member of staff replied that the basic details are written up on the nurses’ communication board when a new resident moves into the home. One relative’s commented in a survey ‘nursing care on the whole has been very good, helping my mother to recover from various bouts of illness and infections’. Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are given the opportunity to take part in a variety of activities. EVIDENCE: On arrival at the home we observed six residents sitting round a table with an activities co-ordinator. Some of the residents were playing dominoes. On another table a resident was knitting. One resident was reading a newspaper and one was reading a magazine. The activities plan for the morning was to do gentle exercise but not enough residents had wanted to take part so they were asked what they would like to do instead. Both of the activities co-ordinators were seen to work with the residents in a kind and considerate manner. One on the co-ordinators pulled a chair and sat Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 15 down and explained to a resident that they were going for a haircut with the hairdresser. During the morning biscuits and drinks were handed round to the residents although one relative of a resident did comment plates and serviettes today – that’s the first time I have seen that’. This was discussed with the manager who stated that tongs are always used to hand biscuits on to a plate. The clock in the lounge said it was 1:40 although it was only 10:10. This could cause confusion for the residents. Relatives of residents that were spoken to during the inspection stated that they were welcome to visit at any reasonable time. All five of the surveys received from relatives confirmed that they are always kept up to date with important issues affecting there relative. One resident said ‘I love it here, the carers are alright, lovely bedroom, I can find no fault’. Of the eight residents’ surveys returned two of them stated that staff listened and acted on what they said, four stated that they usually did and two stated that the staff sometimes listened and acted on what they said. Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Safeguarding procedures have not been followed to ensure the safety of the residents’. EVIDENCE: The complaints policy is on display near the visitors signing in book near the front door. The manager stated in the pre inspection paperwork that 13 complaints had been received by the home. We looked at the record of the complaints and they had all been recorded and dealt with appropriately. All of the residents’ spoken to on the day of the inspection confirmed that they would know who to complain to. Eight surveys were received from residents’, five stated that they knew how to make a formal complaint, 2 said they did not know how to make a formal complaint and one didn’t answer the question. Five surveys were received from residents’ relatives’ and all of them confirmed that they knew how to make a complaint. During the inspection one resident told us that they had been abused whilst in the home. When we spoke to the manager about this she told us that the resident often talked about this and that she thought it was due to their confusion. However there was no written evidence that this had been investigated or that it had been discussed with the adult protection team. The manager was asked to report the allegation to the adult protection team Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 17 immediately and to discuss with them if any further action needed to be taken and to record the outcome. It is important that where allegations are made by residents that these are reported appropriately to the local authority for their investigation. This ensures appropriate records are maintained and people are safeguarded appropriately. When we discussed safeguarding with the staff they stated that they would report any concerns to the manager. Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,23,26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recent renovation and redecoration means the home is generally a pleasant place to live although care needs to be taken to improve infection control measures to ensure that people living and working in the home are protected. EVIDENCE: The home has 4 large sitting rooms and 3 dining rooms. A large ramp has been installed at the door from the rose lounge into the gardens to enable residents’ in wheelchairs to access the garden. Five residents’ surveys stated that the home is usually fresh and clean, two said that it always is and one stated that it sometimes is. Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 19 The majority of the home looked clean and there were no bad odours on the day of the inspection. However the bathroom next to room 37 had an overflowing sangenic bin with used gloves and a used apron spilling out of the top, used gloves on the floor and a trolley in the corner with clothing, hoist sling and incontinence pads on the floor under it. There was also a brown stain on the floor next to the sangenic bin. The toilet next to room 54 had no toilet seat and there is no lock on the toilet door (this was noticed at last year’s inspection). A member of staff stated that the toilet was not used. Residents’ are encouraged to personalise their bedroom. Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are generally satisfied with the care they receive although at times may need to wait to have their needs met. EVIDENCE: We looked at the recruitment, training and supervision records for three members of staff all were found to have the necessary checks and training. All of the staff spoken to confirmed that they had received all of the mandatory training required and some had also completed a dementia course to enable them to work with the residents with dementia more effectively. Two carer workers stated that although they got time to do the basic care they would like to have more time to take over personal care so that they could chat more to the residents. One member of staff stated that when there are only two members of staff for twelve residents they are still getting people out of bed and dressed by midday. The surveys received from the residents showed that two residents stated that staff are always available when they are needed, four stated that they are Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 21 usually available, two stated that they sometimes are and two stated that there are never staff available when they need them. The relative of one resident stated that their relative had to wait forty-five minutes the previous day to be assisted to the toilet as there was only one hoist working. The manager did confirm that two hoists had not been working but that the engineers were coming out to fix them. However the manager stated that they had put extra staff on the morning shift and so would be looking at what issues maybe getting in the way of the staff having more time to spend with the residents’. Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Checks and servicing of equipment is carried out at required intervals, and people are asked their opinion of the home. The management team have not carried out regular checks of care plans, recording of valuables or followed safeguarding procedures to ensure the residents’ are adequately protected or safe in the home. EVIDENCE: The manager is a nurse and is registered with the Nursing and Midwifery Council. She has been managing the home for a number of years and has gained a management qualification equivalent to a NVQ level 4. Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 23 An annual quality assurance survey is carried out, which obtains the views of relatives of people at the home, staff and stakeholders in the community. One member of staff stated ‘the management team are well organised and if you ever have a problem they will give you guidance’. One resident’s relative stated ‘the matron and manager have always been most helpful and supportive’. The requirement to update care plans as residents’ needs change was made at the last inspection and has not been met. Information provided before the inspection says there are monthly residents meetings which are held in various locations throughout the home newsletter to all residents that lets them know what has happened in response to issues they have talked about. We asked the home to complete and return an Annual Quality Assurance Assessment (AQAA) before the inspection. They did this within the time we asked for it. Money is kept by the home on behalf of people living there; access can be gained through the administrator who maintains an accounting system for credits and withdrawals. The records for two people were looked at and found to tally with the money available for these people. People living at the home are also able to keep money with them, if they wish. The home also keeps valuables for residents however there is no record of this so if any was to go missing there would be no record of the home ever having it. The administrator stated that she would ensure there was a record of all valuables handed to the home for safekeeping. Staff files show that staff members receive supervision every 2-3 months and staff members we spoke to also said they had supervision Information provided before this inspection shows equipment, like hoists, lifts and fire-fighting equipment has been serviced or tested as recommended by the manufacturer. Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X 3 X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 2 3 X 3 Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(2)(c) Timescale for action Care plans must be revised when 01/09/09 there is a change in needs and how these are to be met. This is to make sure staff have the most appropriate guidance and people’s needs are met properly Medication must be administered as directed. This will ensure the effectiveness of the medication. 01/08/09 Requirement 2. OP9 13(2) 3 OP18 13(6) 4. OP26 5. OP35 The adult protection procedure must be followed when residents make an allegation of abuse. This will help to protect the residents’. 23(d) All areas of the home must be kept clean and hygienic. This will help to avoid the risk of cross infection and give the residents’ a nice environment to live in. 17(2)Sche There must be a record of dule 4 (9) valuables handed to the home for safe keeping. This will help to protect the residents’ valuables. 01/08/09 01/08/09 01/08/09 Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Littleport Grange DS0000024311.V375979.R01.S.doc Version 5.2 Page 27 Care Quality Commission Eastern Region Care Quality Commission Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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