Inspection on 23/11/06 for Mandeville Grange

This inspection was carried out on 23rd November 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mandeville Grange 04/02/10

Mandeville Grange 23/10/09

Mandeville Grange 11/11/08

Mandeville Grange 29/12/05

Mandeville Grange 28/09/05

Mandeville Grange 14/03/05

Mandeville Grange 10/08/04

Mandeville Grange 28/01/04

Mandeville Grange 21/01/03

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Mandeville Grange 201-203 Wendover Road Aylesbury Buckinghamshire HP219PB Lead Inspector Christine Sidwell Unannounced Inspection 23rd November 2006 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 Mandeville Grange DS0000019240.V312961.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. Mandeville Grange DS0000019240.V312961.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mandeville Grange Address 201-203 Wendover Road Aylesbury Buckinghamshire HP219PB 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) 01296 435320 01296 397509 mg_gbls@hotmail.co.uk Mandeville Care Services Limited Mrs Minerva Patti Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Mandeville Grange DS0000019240.V312961.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. General Nursing Care ( age 50 plus including one 39 plus) Date of last inspection 29th December 2005 Brief Description of the Service: Mandeville Grange Nursing Home is situated on the outskirts of Aylesbury Town, which provides a variety of shops and other local amenities. The home provides nursing care for up to thirty-one residents, who are accommodated on two floors of the building. All floors are accessible by stairs, a passenger lift or stair-lift. Registered nurses and carers staff the home. The Manager is a registered nurse; in addition to managing Mandeville Grange she also manages The Gables Nursing Home, (also owned by the proprietors) which is situated approximately five minutes from Mandeville Grange. Mandeville Grange DS0000019240.V312961.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a period of three days and included an unannounced one-day visit to the home. Prior to the visit all previous information about the home was reviewed. Comment cards were sent to residents and their families and to other professionals who have contact with the home. Nine families, one general practitioner, two healthcare professionals and a care manager returned the comment cards. The care of three residents was case tracked. Residents, staff, family members and the manager were spoken to on the day of the unannounced visit. The home’s approach to equality and diversity was observed. At the time if this inspection the fees range from £500.00 to £690 per week. There are additional charges for hairdressing, chiropody and personal items. Information about the home, including copies of previous inspection reports, can be obtained from the home or by visiting the home at any time. What the service does well: There is information available to residents and their needs are assessed prior to their move to the home, to help them decide whether the home can meet their needs. Residents personal, healthcare and medication needs are met in a timely way and in a manner in which their dignity is protected. The care team have the knowledge and skills to care for people at the end of life giving residents confidence at they will not have to move unless they wish. Residents said that the carers are kind and one family member who returned the comment cards said I am pleased that we found Mandeville Grange. The lifestyle in the home is relaxed and flexible and some activities are undertaken to bring interest and diversion to the day. The meals are home cooked, of a high standard and meet residents nutritional and social needs. All the residents spoken to said that they enjoyed the food. Soft diets and special diets to meet religious or cultural needs are available. Families said that they were welcome at any time. The complaints and safeguarding procedures should reassure residents and their families that concerns will be dealt with and that residents will be protected from abuse. The home is regularly maintained and provides a homely environment for residents although some bedrooms are in need of refurbishment. Mandeville Grange DS0000019240.V312961.R01.S.doc Version 5.2 Page 6 The staffing levels are good and staff have the right attitudes, knowledge and skills to care for residents with complex needs. The residents spoke highly of the carers and the families who returned the comment cards said that, in their opinion, there were always sufficient staff on duty. The home is well managed and provides a safe and secure environment for residents. The manager and the proprietors are experienced care home managers. Routine maintenance of equipment and systems is undertaken. 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 Mandeville Grange DS0000019240.V312961.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. Mandeville Grange DS0000019240.V312961.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mandeville Grange DS0000019240.V312961.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement was made using available evidence, including an unannounced visit to the service. There is information available to residents and their needs are assessed prior to their move to the home, to help them decide whether the home can meet their needs. EVIDENCE: There is a statement of purpose and service users guide. A copy of the service users guide was seen in seen in residents rooms. The manager said that she or one of the registered nurses always visited potential residents before they moved to the home and always reassesses residents if they have been in hospital to ensure that the home can continue to meet their needs. Evidence of pre-assessment visits was seen in residents care plans. The documentation used conforms to the recommendations of the Care Homes National Minimum Standards 2003. Mandeville Grange DS0000019240.V312961.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is good. This judgement was made using available evidence, including an unannounced visit to the service. Residents personal, healthcare and medication needs are met in a timely way and in a manner in which their dignity is protected. The care team have the knowledge and skills to care for people at the end of life giving residents confidence that they will not have to move unless they wish. EVIDENCE: The care of three residents was case tracked. All residents have a care plan. There was evidence in the files that their care needs had been assessed by a care manager where necessary. There was also evidence in the files that residents entitlement to a contribution to fees from the National Health Service in respect of their nursing needs had been assessed. The care plans seen had been reviewed on a monthly basis. Two residents spoken to said that they had been involved in drawing up their care plan and six of the nine family members who returned the comment cards said that they had been consulted about their family members care. There was evidence in the care plans that residents risk of developing pressure damage is assessed and monitored regularly. Those residents who were at risk had appropriate pressure damage relieving mattresses. Two residents had been admitted from Mandeville Grange DS0000019240.V312961.R01.S.doc Version 5.2 Page 11 hospital with pressure damage. They had appropriate care plans in place and the damage was healing. Manual handling assessments had been undertaken and an appropriate care plan developed. Residents had had nutritional assessments and their weight was monitored. None of the case tracked residents had lost weight. There was evidence in the files that residents have access to the services of the local Primary Care Trust (PCT) and one resident spoken to said that she was pleased to still see her own general practitioner. There are medication policies and procedures in place. The staff spoken to said that medication is never administered covertly. The Royal College of Nursing Guidelines on this are available. Records of medication entering and leaving the home are kept. The medication administration records were completed accurately. There are protocols in place, agreed with the local general practitioner, to enable nurses to administer homely remedies. The controlled drug cupboard was checked and the controlled drugs were found to be managed correctly and accurately recorded. The cupboard was however used to store other valuables and this should be reviewed. The care staff were observed to be respectful to residents. All personal care was given in residents rooms. The general practitioner, healthcare professionals and care manager who returned the comment card said that they were able to see residents in private. Service users were wearing their own clothes and those spoken to were happy that carers addressed them by the name which they preferred. The home works closely with the local hospice and provides care to residents in the last phase of their lives. The nurses spoken to were knowledgeable about palliative care. The care manager who returned the comment card said that Mandeville Grange had provided good care for several complex and sensitive palliative care patients from the local hospice. They are proactive in seeking advice so they are able to provide high quality care. Mandeville Grange DS0000019240.V312961.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is good. This judgement was made using available evidence, including an unannounced visit to the service. The lifestyle in the home is relaxed and flexible and some activities are undertaken to bring interest and diversion to residents day. The meals are home cooked, of a high standard and meet residents nutritional and social needs. EVIDENCE: The home employs an activities coordinator, although she has had to reduce her hours recently due to family circumstances. The layout of the home provides space for activities to take place and a daily crossword and conversation group is held in one lounge. One resident spoken to said that he enjoyed the activities. He had a good record in his care plan of his likes and dislikes and his social history. Other activities include dominoes and gentle ball games to improve coordination. The activities coordinator also said that she read to residents, including reading the Bible to one lady who is blind. The carers spoken to said that residents had a choice as to when they got up or went to bed. There was evidence in the home that group activities and outings take place on occasions. The chef always makes a birthday cake. One lady was very upset that she felt trapped and the staff were seen to help her gently and to try to ensure that she had something to do. The activities could be improved by the development of individual activities and by involving all staff in the provision of day-to-day diversion for residents. The families who returned the comment cards said that they were welcome at the home at any Mandeville Grange DS0000019240.V312961.R01.S.doc Version 5.2 Page 13 time and that they were able to visit their relative in private if they wished. The two residents spoken to said that they were given a choice although one said they are busy, I try to fit in. The main meal served on the day of the unannounced visit was beef casserole with three vegetables, including potatoes, and ginger sponge with custard. The meals are home cooked. An evening chef is employed and the supper on that evening was soup, macaroni cheese and soup. The chef said that she didn’t have any one who wanted a special diet for religious reasons at the moment but had had in the past and was able to meet their needs. She noted that one Italian gentleman enjoyed his pasta. She also had a record of residents likes and dislikes and made a point of visiting the residents to ensure that they were happy with their meals. Soft diets were presented attractively. One family member who came in most days to assist her mother with her lunch said that the food was always of a high standard. The chef said that she prided herself on providing home cooking. There was no evidence of commercially prepared food in the kitchen. The main meal served at 12.30 was seen to be a sociable occasion. Mandeville Grange DS0000019240.V312961.R01.S.doc Version 5.2 Page 14 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): 16 and 18 Quality in this outcome area is good. This judgement was made using available evidence, including an unannounced visit to the service. The complaints and safeguarding procedures should reassure residents and their families that concerns will be dealt with and that residents will be protected from abuse. EVIDENCE: There is a complaints policy and procedure in place. Six of the nine family members who returned the comment cards said that they were aware of the complaints procedure. One said that she had made a minor complaint, which had been dealt with immediately. A record is kept although no complaints have been recorded. The Commission for Social Care Inspection has not received any concerns or complaints since the last inspection. The home has a copy of the Buckinghamshire Social Services multi agency strategy for the protection of vulnerable people and the staff spoken to were aware of the steps to be taken if an allegation is made or there is concern about potential abuse. The training records showed that staff had had training in the protection of vulnerable adults. The Commission for Social Care Inspection has not been notified of any safeguarding referrals, made to the local authority under their procedures, since the last inspection. Mandeville Grange DS0000019240.V312961.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This judgement was made using available evidence, including an unannounced visit to the service. The home is regularly maintained and provides a homely environment for residents. The infection control procedures should be improved if residents are to be protected from acquired infection arising from their care needs. EVIDENCE: The building is an Edwardian house with an extension and as such provides a variety of rooms for residents. There is a programme of maintenance and there was evidence that some rooms have been redecorated in the last year. It was clean and tidy on the day of the unannounced visit. There were no offensive odours. The grounds were tidy and very attractive. One resident said that he enjoyed his daily walk in the garden although he had been advised by staff not to walk out of sight of the home. The courtyard area was attractive and very suitable for those who used a wheelchair. Residents are encouraged to personalise their rooms and some had chosen to do so. Some furniture provided by the home is shabby and needs replacing. Not all residents who required nursing care had height adjustable beds and a programme to provide these over a period of time should be set. There are Mandeville Grange DS0000019240.V312961.R01.S.doc Version 5.2 Page 16 control of infection policies and procedures in place, which the staff were aware of. Alcohol gel is available as a hand rub for staff to help reduce the potential for cross infection. Protective clothing is worn. Not all bins had lids and this must be addressed. The slings used with the hoist are shared. Thirteen residents need to be moved using a hoist at the present. The manager and staff nurses said that all slings are washed every night. If a sliding sheet is needed each resident has their own. The manager said that if a resident has an infection they would have their own sling. Despite the precautions taken it is not good practice for slings to be shared as there is a risk of cross infection. Residents should have their own hoist slings, which are washed regularly. Mandeville Grange DS0000019240.V312961.R01.S.doc Version 5.2 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, 28, 29 and 30 Quality in this outcome area is good. This judgement was made using available evidence, including an unannounced visit to the service. The staffing levels are good and staff have the right attitudes, knowledge and skills to care for residents with complex needs. EVIDENCE: A staff rota is kept. On the day of the unannounced visit there was one registered nurse and five carers on duty. The staff nurse said that there were usually two registered nurses on duty and the records seen confirmed this. There are more staff on duty during the busy times of the day. The atmosphere was calm and the staff spoken to say that whilst they would always like more staff they felt that the staffing levels were sufficient to meet residents needs. The call bells were answered promptly. Of the nine family members who returned the comment cards all said that they felt that there were always sufficient staff on duty. Only three staff members have left during the last year, two to work in the local hospital and one who moved out of the area. The home has a bank of nurses and does not use agency nurses. The home was clean and tidy on the day of the inspection and there is sufficient catering staff to provide a reliable service. Five of the current care staff hold the National Vocational Qualification in Care at Level 2 or above, three are undertaking the course and further two have registered to start the course at the next intake. The home does not yet meet the standard that 50 of care staff hold this qualification although has a plan to do so and is encouraging staff to develop their skills. Mandeville Grange DS0000019240.V312961.R01.S.doc Version 5.2 Page 18 The recruitment files of four staff members were checked. They all had checklists at the front identifying the records that should be held and the checks that should be undertaken before a staff member commenced work, although these were not all complete. All staff had completed an application form. There were interview records in two files. Two references had been taken up on each candidate before they commenced work. There was a sticker on the front recorded. There was no evidence that the staff member whose full criminal records disclosure had not been received had been checked against the POVA register and the results of the POVA first was not available. The manager subsequently located this and the inspector was told that this was now available. There was evidence in one file that the qualified nurse was registered with the Nursing and Midwifery Council (NMC) but not in all. It was subsequently confirmed that all nurses had current registration with the NMC. Not all staff members had copies of their work permits on file. Whilst all the required information was eventually confirmed the files were not tidy and fully up to date. This needs to be addressed. It is recommended that recruitment practices be reviewed in line with guidance recently issued by the Commission for Social Care Inspection. The training records were examined and showed that all staff had had mandatory training during the year. The staff spoken to confirmed this. Some staff have also had training in end of life care, dementia care, diabetic foot care and emergency first aid training. A new member of staff spoken confirmed that she was working through an induction programme and was supported by an experienced carer. Mandeville Grange DS0000019240.V312961.R01.S.doc Version 5.2 Page 19 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): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement was made using available evidence, including an unannounced visit to the service. The home is well managed and provides a safe and secure environment for residents. Fire safety is generally well managed although advice must be sought from the fire service regarding the placing of hold open devices on fire doors if residents are to be fully protected from potential fire risks. EVIDENCE: The manager stated that she had been involved in and managed care homes for twenty-two years. The staff spoken to that the atmosphere was open and they felt confident to approach her. She is registered with Commission for Social Care Inspection. She is not undertaking the National Vocational Qualification in Management at Level 4 at present. The manager described the quality assurance programme. A residents and families questionnaire had been undertaken recently. The response was good and the manager said that Mandeville Grange DS0000019240.V312961.R01.S.doc Version 5.2 Page 20 the questionnaires would be analysed to ascertain themes and see where improvements could be made. The manager stated that the proprietors were working on the annual development plan. The proprietor makes regular visits in line with Regulation 26 of the Care Homes Regulations. Action has been taken to address most of the requirements of the previous report. The home manages some personal allowance on behalf of residents. This was in the main well managed and receipts were given for all money and valuables handed to the home for safekeeping. However the drug cupboard was found to contain a purse, other valuables and loose money belonging to residents. The staff said that they did not have anywhere to put valuables given to them out of office hours. Safe storage for valuables, for use by staff out of office hours, and a method of recording what is placed in this storage should be provided. The pre-inspection questionnaire indicated that regular maintenance of the homes equipment and systems is undertaken. A sample of maintenance records was checked to confirm this. A fire risk assessment was undertaken on the 14/11/06 and the manager stated that an action plan would be developed to address the risks identified. The fire log was up to date and the staff spoken to could describe the fire evacuation procedures. Dorguards hold open devices are fitted to fire doors open if residents do not like them shut. These appliances automatically close doors if the fire alarm sounds. A dorguard hold open device is also fitted to the kitchen door, which is not in line with the usual recommendations of the fire service. Staff told the inspector that the kitchen became very hot if the door was closed. It is a requirement of this report that written confirmation is sought from the fire authority that the fire door hold open devices in situ in the home are placed in suitable positions and that fire safety is not compromised. Health and safety policies are in place and COSSH assessments have been undertaken. Accidents are recorded and the staff spoken to understood the requirement to report serious accidents and injuries. Mandeville Grange DS0000019240.V312961.R01.S.doc Version 5.2 Page 21 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 3 8 3 9 3 10 3 11 3 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 3 2 X X X 2 X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X 2 3 Mandeville Grange DS0000019240.V312961.R01.S.doc Version 5.2 Page 22 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 OP26 Regulation 13(3) Requirement Timescale for action 31/01/07 2 OP35 16(2) 3 OP38 23(4)(c) The proprietor should ensure that individual hoist slings are available for residents who need them. The proprietor should provide 31/01/07 safe storage for residents valuables in the home, for use by staff when the office is closed. The proprietor should ensure 31/12/06 that doors are not to be held open with a hold open device unless the location is approved by the fire officer. This is an unmet requirement of the previous inspection and a new timescale has been set. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP13 Good Practice Recommendations The activities could be improved by the development of individual activities and by involving all staff in the DS0000019240.V312961.R01.S.doc Version 5.2 Page 23 Mandeville Grange 2 3 4 OP19 OP24 OP29 provision of day-to-day diversion for residents The refurbishment of individual rooms should continue. The proprietor should agree a programme to provide height adjustable beds for all residents requiring nursing care of a defined timescale. The proprietor should review the recruitment practices and procedures in line with guidance issued by the Commission for Social Care Inspection and available on the website www.csci.org.uk Mandeville Grange DS0000019240.V312961.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Mandeville Grange DS0000019240.V312961.R01.S.doc Version 5.2 Page 25 - 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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