Inspection on 10/05/06 for The Grange

This inspection was carried out on 10th May 2006.

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

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

Other inspections for this house

The Grange 27/09/05

The Grange 03/05/05

The Grange 20/01/05

The Grange 18/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE The Grange 154 Reddish Road Reddish Stockport Cheshire SK5 7HZ Lead Inspector Kath Oldham Unannounced Inspection 10th May 2006 08:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Grange DS0000008556.V293272.R01.S.doc Version 5.1 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. The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Grange Address 154 Reddish Road Reddish Stockport Cheshire SK5 7HZ 0161 476 0702 0161 476 0702 zyasin@tiscali.co.uk 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) Mr. Zahid Yasin Mrs Bobbie Baljit Walia Mrs Bobbie Baljit Walia Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 18 OP. Date of last inspection 27th September 2005 Brief Description of the Service: The Grange is a detached care home situated in the Reddish area of Stockport, close to local amenities. The Granges current owners, Mr Yasin and Mrs Walia, purchased the property in February 2001. The home is registered to provide care for 18 elderly service users. Accommodation is available on two floors, with the majority of bedrooms being on the first floor. Access to the bedrooms on the upper floor is by means of stairs, passenger lift or chairlift. A number of bedrooms on the upper floor cannot be accessed by the lift. There are gardens with a fence around the perimeter. Off road parking is available at the front of the house. The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for the inspection was undertaken on 10th May 2006, commencing at 8:00am. The visit was used to evaluate how the home had complied with the requirements and recommendations from the last inspection, which was undertaken in September 2005. Some of these had been achieved in full, others had been partially achieved, others have not yet been addressed and are repeated. There were 12 service users accommodated at the home, two of whom were in hospital. Time was spent on the site visit examining records and in discussion with service users. Families and friends who came to the home during the visit were also spoken with. Comment cards were given to the deputy manager to distribute to service users and also to staff working at the home to provide them with an opportunity to comment on the home, care and support. The comments received are included in this report. The manager was asked to forward to the inspector the names and addresses of service users’ relatives or friends so a comment card could also be sent to them. This information was not forwarded to enable comment cards to be sent out. The inspector distributed some comment cards to relatives during the site visit. A partial inspection of the premises was also undertaken and comments in relation to this are included in this report. Two care staff were on duty during the visit. Two housekeeping staff work at the home providing 8.5 cleaning hours each day during the week. The cook has left her employ and the manager is undertaking meal preparation during the week and the sleep-in staff member prepares breakfast and cooks at weekends. The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The kitchen had new cupboards installed, which were reported on at the last inspection. Tiling and a couple of finishing touches continue to need completing. The bedrooms that need new furniture are waiting for these to be fitted. The last inspection reported that it was the registered persons’ intention to have these fitted in the weeks after that inspection. These have not all been done. There continue to be a number of areas of the home which need recarpeting. The carpets in the conservatory and lounge and a large number of bedrooms need priority, as they look shabby and worn. One double bedroom carpet on the ground floor is very heavily stained. The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 7 Staff need training to NVQ level 2 in direct care. The home also needs to be mindful to ensure that all staff are included in training in the home. Sleep-in staff must also be included to ensure that they and service users are safeguarded. Contracts of employment were not retained on staff files and staff said they had not got a contract. Job descriptions were also not available. The developments introduced at the home need to continue. The care plans need to be individualised to the service user to make sure the care that they need is detailed and which is pertinent to them, this will ensure that care staff know exactly what they need to do for each service user. Activities in the home are lacking and some service users have no stimulation at all throughout the day. The administration and recording of controlled drugs need to be improved upon to ensure service users receive the correct medication and the recording is in keeping with the Royal Pharmaceutical Society’s guidelines and required practice. 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 Grange DS0000008556.V293272.R01.S.doc Version 5.1 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 The Grange DS0000008556.V293272.R01.S.doc Version 5.1 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): 1, 2, 3 & 5. Standard 6 is not applicable. Quality in this outcome area is adequate. Sufficient information is not provided to all service users to enable them to make an informed choice about living at The Grange, and service user assessment is not fully implemented. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the service user guide and statement of purpose was provided on the site visit. The manager stated that new service users have a copy of the guide in line with regulations. The statement of purpose continues to need some development to include all aspects of the regulations. Service users spoken with were not aware whether they had received this documentation. The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 10 Service users and/or their relatives were given the opportunity to visit the home before making the decision to move in for a trial period of six weeks. A contract or terms and conditions of residence were not observed in all the care files examined. An assessment completed by the home was not always included in the care files. The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 11 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 Quality in this outcome area is adequate. Care plans do not address all areas of need. satisfactory. Medicines management is not This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users were neatly presented and attention had been paid to personal grooming. Staff interacted with service users in a relaxed and pleasant manner. Care planning documentation was seen. The care plan continues to need development to detail the specifics of the care provided for the individual. On evaluation, the effectiveness and the quality of information within the care files was inconsistent. The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 12 Service users’ weights are undertaken monthly, with a record maintained of weight gain or loss. Comments are also recorded of any actions taken as a result of this. The daily reports did not always detail the support, care or interventions provided by staff. Some of the entries included staff saying how they thought service users felt. The daily reports for two service users, one who had been unwell, had not been completed the day and night prior to the site visit so it was not recorded how the service users had been. District Nursing staff attend the home to provide health care to a number of service users. Records were available of the community health and medical services used by the home for each service user. Medication administration was observed for a number of service users. Staff took into account service users’ abilities and prompted and encouraged service users to take their prescribed medication. None of the service users who were living at The Grange were in charge of their own medication for various reasons, such as not wishing to take the responsibility or mental health problems. Examination of the medication records identified that, in the main, they were completed appropriately. Labels were attached to the records, which is not safe practice. If medication is prescribed once the records have been printed, then handwritten changes should be made which should also be signed and verified by a second staff member. One service user was recorded as having been given a different dosage of medication than that printed on the medication records. The manager stated that this had been changed by the service user’s doctor the month previously. The recording in the controlled drugs book was not in keeping with regulations. A senior member of staff signed the records for the day prior to the visit before giving them to the inspector. The balance for one service user was incorrect so the stock had not been counted as suggested by the senior. Medication is administered by senior carers who have received basic training in the handling and administration of medication. The manager stated that staff were to take part in a 12 week medication course in forthcoming weeks. The home does not carry out any formal assessment of carer competency. Improvements have been made in the storage of medication which safeguards service users’ health and wellbeing. The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 13 The inspector saw that the service users’ rights to privacy were being respected, as bathroom doors were shut and staff knocked or called out before entering. Bedroom doors were wedged open. This practice compromises the health and safety of service users and does not promote their privacy and respect for their personal space and possessions. The Grange DS0000008556.V293272.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is poor. Service users are not provided with opportunities for activity during the day. Mealtimes were relaxed and informal and met service users’ needs. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: As reported on previous inspections, service users do not routinely go out of the home unless with their own relatives. Service users should be provided with opportunities to go out of the home. The manager said she had a member of staff who she was considering approaching to see if they would carry out some activity with service users. The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 15 Service users were observed sitting in the lounge for long periods, with no opportunities for mental or physical stimulation. Service users were sat in front of the television with the sound turned down and a member of staff put on music, no conversation about whether they wanted music on took place. Some service users were looking towards the television, unaware that the sound was from the music centre. There is no menu plan; staff said they cook what is in. A board in the dining room indicates the meal for the day. One service user has a cooked breakfast each day. A record of food is maintained at the home. The record, in the main, indicates that all service users have the same meal and accompaniments. One service user said, “they always do a good dinner”. Fridge and hot probe temperatures were recorded. Freezer temperatures and a kitchen-cleaning schedule were not. The manager and deputy have obtained food hygiene training which safeguards service users. A further staff member needs to undertake this training to ensure standards are maintained and safe practice is undertaken when preparing meals. Service users said they could get up and go to bed at times that suited them. Service users confirmed that visitors were made welcome at the home and service users kept in touch with family and friends. A number of relatives and visitors were in the home on the site visit. The Grange DS0000008556.V293272.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. For the most part, residents were protected. need development. However, training and policies This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The home had a complaints policy and procedure; there had been no recorded complaints since the last inspection. One service user told the inspector that she had no reason to complain and that they were quite satisfied with the care provided. The home had a procedure for responding to allegations of abuse. The abuse policies and procedures continue to need development. The majority of staff had completed training in the protection of vulnerable adults. New staff need to be put forward for this training. The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 & 26 Quality in this outcome area is poor. The environment does not promote the safety, security, comfort and respect of service users. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The environment does not have an ongoing maintenance programme in place. A number of the fixtures and fittings need replacement and some of the décor requires upgrading. The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 18 Service users said they were given the opportunity to bring in personal possessions and small items of furniture. There is a lounge and conservatory and a communal dining room. The lounge has been redecorated and new curtains have been put up. The carpets continue to need replacement, as they are shabby and appear dirty. The manager said they had the carpets cleaned. The ceiling in the lounge above the bay window continues to need attention as the paper, and possibly the plaster, is cracked and is coming away. The lounge leads to the conservatory where service users are able to smoke. Due to the smoking habits of service users, the smell of cigarette smoke and smoke was obvious in the lounge area. The smoke affected those service users who choose not to smoke or sit in the lounge. Mechanical air extraction must be provided to promote the comfort of service users who do not smoke. The manager said that due to the lack of service users at the home, finance is not available to address these points. Some of the service users’ bedrooms have had some improvements. One service user said she had her walls painted again in the same colour, which makes them look much brighter. A number of bedroom doors were wedged open, which compromises the health and safety of service users and staff and does not promote the privacy and respect of service users or their possessions. One of the bedrooms contains a shower, which didn’t appear to be connected to the water supply. The room is currently vacant. The downstairs bathroom was out of commission, there had had a leak and the floor was unsafe. The deputy stated that enquiries had been made regarding the upgrade of this bathroom. There are six toilets in the home, three are separate to the bathing facilities. There are four bathrooms, one provides an assisted bath. There are no ensuite facilities within service users’ bedrooms. One bathroom was now used as a storeroom. The door was not locked and service users could be at risk if they were to go into the room. Bathrooms would benefit from redecoration; the rooms appearing cold and unwelcoming. There continues to be a need to replace the shades on the light fittings in the bathrooms and toilets. The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 19 Service users are able to use a lift to the first floor. Six bedrooms are not accessible directly from the lift; service users are able to use a chairlift up the remaining stairs to these bedrooms. The home was clean and free from odours. Service users said the home was always clean. The Grange DS0000008556.V293272.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. Staff are safely employed in sufficient numbers to meet care needs but training is not provided to ensure care practice is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two staff were on duty providing care to service users and two housekeepers. The sleep-in staff member stayed on duty cooking breakfast until the arrival of the manager. A cook is no longer employed at the home; the manager and sleep-in staff member are currently undertaking cooking duties. The manager and deputy have been successful in obtaining food hygiene training. The sleep-in does not. There are no staff employed at the home to undertake laundry duties. Care staff undertake laundry which reduces the time for direct care. Several staff had worked for many years in the home with the continuity of care benefiting the service users. The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 21 Examination of staff files identified that Criminal Record Bureau checks had been obtained for a newly appointed staff member, a POVA check had been undertaken prior to the staff member commencing employment. The registered manager had followed recruitment procedures in regard to newly appointed staff. New staff had completed a period of induction to assist in the development of their role. This training is provided away from the home. The manager stated staff had completed moving and handling training. There were no certificates on file to confirm this. The manager did say on the last inspection that she was to observe practice to ensure techniques are correct and undertake an evaluation of the training to confirm staff are competent. This has not been undertaken. Staff training for the National Vocational Qualification (NVQ) award had not developed. Two staff have now obtained this training. The registered person should encourage the care workers to complete their NVQ as soon as possible, so that the home meets with the National Minimum Standards. There was no evidence of a training plan for the staff group. The Grange DS0000008556.V293272.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. Management systems and health and safety practices have improved but still require further development. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The manager, who is also one of the owners, has been registered with the Commission for Social Care Inspection to be the manager of the home. The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 23 The manager continues in her studies to obtain NVQ 4 in management and needs to complete the training as soon as possible, so that the home meets with the National Minimum Standards. Staff were complimentary regarding the skills of the deputy and said that they had learnt a lot from her. Examination of the accident book identified 20 accidents from October to March 2006. The record was completed fully in line with Data Protection legislation. An accident analysis is not currently undertaken by the home. Previous inspections have made this a requirement. The record did not detail any accidents after March 2006. The fire safety checks were recorded as being undertaken as required by the fire authority. All staff had recorded their receipt of fire drill training and practice. The manager said that service user meetings are not routinely arranged but that she has spent time with service users individually, asking specific questions to obtain their views and opinions. The last recorded event took place in September 2005. Service users admitted after this time have not been given this opportunity. All the equipment in the kitchen was reported by the cook on duty to be in working order. A record is maintained of the refrigerator and hot probe temperatures, which are detailed daily in the kitchen records, in line with environmental health regulations. Freezer temperatures are not recorded. A kitchen-cleaning schedule was not in place. This record should detail the daily cleaning tasks. The cook said the kitchen is cleaned and the floor is mopped daily. Risk assessments relating to working practices at the home have yet to be drawn up to ensure that, where risks are identified, adequate strategies are in place to replace the risk. The manager stated that some monies are held on behalf of service users for hairdressing and chiropody. This record is maintained at the registered person’s home and is brought in weekly. The home has recently achieved the Investors in People award. The Grange DS0000008556.V293272.R01.S.doc Version 5.1 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 2 2 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 2 X X 2 X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 25 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 OP1 Regulation 4 Requirement Timescale for action 30/06/06 2 OP2 4.8 3 OP3 14(1) The registered person must update the Statement of Purpose to include the information identified in Regulation 4.1(a)(b)(c) and Schedule 1 of the Regulations. (Previous timescales of 28/02/05 and 31/12/05 not met). The registered person must 30/06/06 ensure that a contract or terms and conditions are provided to all service users and a copy signed by the service user or their representative is maintained on file. (Previous timescales of 30/06/05 and 31/12/05 not met). 30/06/06 The registered person must ensure that an assessment is undertaken for all service users prior to their entering the home and this assessment is used to develop care plans. (Previous timescales of 30/06/05 and 31/12/05 not met). The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 26 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. 4. Standard OP7 Regulation 15 Requirement The registered person must update the care plan to reflect the action to be taken by care staff to ensure all aspects of health, personal and social care needs of the service user are met. (Previous timescales of 30/06/05 and 31/12/05 not met). The registered person must ensure that staff complete the controlled drugs book accurately and ensure they are aware what they are signing for. The registered person must ensure that a policy is developed which covers the storage, administration and recording of homely remedies. (Previous timescales of 31/03/05, 30/06/05 and 31/12/05 not met). The registered person must ensure that the competency of carers with responsibility for medication administration is assessed regularly on a formal basis. Timescale for action 30/06/06 5 OP9 13 10/06/06 6 OP9 13(2) 30/06/06 7 OP9 13 &18 01/07/06 The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 27 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. 8 Standard OP12 Regulation 16(2)(m) Requirement Timescale for action 10/07/06 9 OP15 16(4)(13) 10 OP15 18(1)(c) 11 OP16 22 The registered person must consult with service users about their social interests and make arrangements to enable them to engage in local, social and community activities and to visit places of interest outside of the home. (Previous timescales of 30/09/04, 31/03/05, 30/06/05 and 31/12/05 not met). The registered person must 10/06/06 ensure that the home has a menu which provides alternative meals. (Previous timescales of 30/06/05 and 31/12/05 not met). The registered person must 30/06/06 provide staff responsible for food preparation with training to enable them to safely prepare meals for service users. (Previous timescales of 31/03/05, 30/06/05 and 31/12/05 not met). The registered person must 30/06/06 further develop the complaints procedure to include the routine of recording complaints and comments received by the home. The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 28 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. 12 Standard OP18 Regulation 13(4), 13(6), 37 Requirement Timescale for action 30/06/06 13 OP19 16(2)(c) 14 OP20 23(2)(n) (p) 15 OP21 23(2)(p) The registered person must ensure that all staff are familiar with the procedures to protect service users from abuse, ensuring the theory is transferred into practice. (Previous timescales of 30/09/04, 31/03/05, 30/06/05 and 31/12/05 not met). The registered person must 30/06/06 replace the carpets in the lounge and conservatory. (Previous timescales of 31/03/05, 30/06/05 and 31/12/05 not met). The registered person must 10/07/06 provide mechanical air extraction in the conservatory to ensure smoke does not pervade the lounge areas of the home. (Previous timescales of 31/03/05, 30/06/05 and 31/12/05 not met). The registered person must 10/07/06 install light shades to light fittings in all bathrooms and toilets. (Previous timescales of 28/02/05, 30/06/05 and 31/12/05 not met). The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 29 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. 16 Standard OP24 Regulation 23(c)(b) Requirement The registered person must replace the broken drawers within service users’ bedrooms. (Previous timescales of 31/03/05, 30/06/05 and 31/12/05 not met). The registered person must ensure that there are sufficient, laundry staff on duty to ensure care delivery is not compromised by care staff performing these duties. (Previous timescales of 30/09/04, 28/02/05, 30/06/05 and 31/12/05 not met). The registered person must provide evidence of how they intend to provide training to care staff to ensure that 50 of staff are trained to NVQ Level 2. (Previous timescales of 28/02/05, 30/06/05 and 31/12/05 not met). The registered manager must conclude NVQ 4 training in management and forward to CSCI confirmation of obtaining certification. The registered person must ensure that quality assurance systems, an annual development plan and an audit system are put in place. (Previous timescales of 30/09/04, 31/03/05, 30/06/05 and 31/12/05 not met). DS0000008556.V293272.R01.S.doc Timescale for action 30/06/06 17 OP27 18 30/06/06 18 OP28 18 10/06/06 19 OP31 9 30/06/06 20 OP33 24 30/06/06 The Grange Version 5.1 Page 30 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. 21 Standard OP38 Regulation 16(2)(i) Requirement Timescale for action 11/05/06 22 OP38 37 23 OP38 13.4 The registered person must ensure that freezer temperatures are recorded at the regularity as defined within food hygiene regulations. (Previous timescales of 30/06/05 and 31/12/06 not met). The registered person must 10/05/06 notify the commission in writing of any event that affects the health, safety and well-being of service users, as defined within the regulation. The registered person must carry 30/06/06 out risk assessments for all working practices and record significant findings. Research legislation to ensure knowledge and compliance. Obtain checks to the regulation of water temperatures and design solutions to control risks from hot water/surfaces ensuring the systems are in keeping with Health and Safety legislation. The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 31 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 Refer to Standard OP4 OP7 Good Practice Recommendations The registered person should provide staff with training in care for service users with dementia. The registered person should provide staff with direction and guidance in how to complete the daily records, ensuring that the content details the care and support provided and the language used is not judgemental. The registered person should update the abuse policies. The registered person should, when a shared room becomes vacant, provide the service user with the opportunity to choose not to share, by moving to a different room if necessary. The registered person should replace the carpets and curtains in service users’ bedrooms. Conduct an audit of the condition of furniture and furnishings and replace them in a timely manner. The registered person should ensure that interviews are recorded and maintained on individual staff files with a written record of questions and responses provided. The registered person should provide to all staff employed at the home an up to date contract of employment, a copy of which should be kept on their personal file signed by staff. The registered person should produce a central record of all staff training to assist in the collation of this information and to assist in the planning for future training events. 3 4 OP18 OP24 5 OP24 6 7 OP29 OP29 8 OP30 The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 32 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 The Grange DS0000008556.V293272.R01.S.doc Version 5.1 Page 33 - 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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