Inspection on 27/09/05 for The Grange

This inspection was carried out on 27th September 2005.

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

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

Other inspections for this house

The Grange 10/05/06

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 27th September 2005 08:15a 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.V253401.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Grange DS0000008556.V253401.R01.S.doc Version 5.0 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 Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places The Grange DS0000008556.V253401.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 18 OP. Date of last inspection 3rd May 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.V253401.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the day in September 2005. The inspection was undertaken to monitor the management of the home, to evaluate how the home was addressing the requirements and recommendations and to discuss the home’s plans to improve the environmental standards. Time was spent observing staff practices and routines, a partial inspection of the building, examination of records maintained for the purpose of regulation and conversation with service users. The registered persons, acting manager and deputy were in attendance at the inspection. There has been one visit undertaken to the home since the last inspection in June 2005. This inspection was undertaken to examine files that were not available at the previous inspection. An additional visit letter was sent to the registered person identifying the actions that were needed as a result of that visit. What the service does well: What has improved since the last inspection? The trees to the front of the home have been removed which has enhanced the front gardens. The registered person said that they intend to landscape the gardens in 2006. Some new bedroom furniture has been purchased and five of the bedrooms have benefited from new wardrobes and drawers. The remaining bedrooms that need new furniture are having these installed in forthcoming weeks. The Grange DS0000008556.V253401.R01.S.doc Version 5.0 Page 6 New curtains have been put up in the dining room which complements the repainting of the walls and the new carpeting which was installed some months ago. The kitchen has had new cupboards installed and this installation is near completion. Tiling and a couple of finishing touches need to be completed. The cook said the kitchen is much easier to keep clean and tidy. Some of the bedrooms have had new curtains fitted, which again enhances their appearance. The outside of the house has received some preliminary work to improve the appearance. A number of windows do need replacement. In the interim, remedial work has been undertaken to make safe and improve the draughts from these windows. The registered person said that this was within the home’s annual development plan. Additional standard lighting has been positioned in the lounge in an attempt to improve the light in this room. Thirty-three requirements were issued or brought forward on the last inspection. The home has fully addressed 15 of these and some have been partially achieved. These are repeated until such time they have been fully complied with. Out of the 12 recommendations detailed on the last inspection three have been fully addressed by the home. Moving and handling techniques were observed to be in keeping with practice guidelines and all service users were transferred in wheelchairs appropriately. What they could do better: There continue to be a number of areas of the home which need redecoration and recarpeting. The conservatory and lounge and a large number of bedrooms are included in the plans to update and rejuvenate the home. Staff need training to NVQ 2 in direct care. Attention to detail needs to be promoted in the recruitment of staff, ensuring the essential CRB checks are undertaken before staff start employment. 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 in training to ensure that they and service users are safeguarded. The Grange DS0000008556.V253401.R01.S.doc Version 5.0 Page 7 A number of the requirements of this inspection have now been repeated on at least three previous inspections. The owner has been informed that action on these requirements must be a priority. 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.V253401.R01.S.doc Version 5.0 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.V253401.R01.S.doc Version 5.0 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 Sufficient information is not provided to all service users to enable them to make an informed choice about living at The Grange. EVIDENCE: The service user guide and statement of purpose are a combined document and this needs to be updated. In its current format, it does not detail all the information service users should have about the home. The deputy stated that newly admitted service users’ families have received a copy of the service user guide. Service users who have been at the home for some time could not recollect having seen a copy. One service user said they may have had it and forgotten. The Grange DS0000008556.V253401.R01.S.doc Version 5.0 Page 10 A contract or terms and conditions of residence were not observed in the care files examined. An assessment completed by the home was not included in the care files examined. In one case this was due to the service user coming from the south of England. A local authority assessment was in place for this person. The Grange DS0000008556.V253401.R01.S.doc Version 5.0 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 Shortfalls in the recording on service users’ care plans has the potential to place them at risk of not receiving the care and support they need. EVIDENCE: A care plan was in place in service users’ files examined. The care plan included a risk assessment and detailed a record of a review of the care provided. The care plan continues to need development to detail the specifics of the care provided for the individual. A record is maintained of GP visits and optical checks within service users’ care files. The home has had some difficulty obtaining dental services for some of the service users; this has now been remedied with the dentist visiting the home. Service users were confident that if and when they needed health care visits, this would be arranged by the home. 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 Grange DS0000008556.V253401.R01.S.doc Version 5.0 Page 12 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. 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. Medication administration and controlled drugs records were up to date with no omissions evident. The medication records included the date of receipt and number of medicines received at the home. A policy is now in place in relation to non-prescribed medication to ensure that staff are aware of when and if service users can have access to over-thecounter medicines. The pharmacist inspector will provide feedback to the home in relation to its content to assist in the home’s development. Improvements have been made in the storage and recording of medication which safeguards service users’ health and wellbeing. One of the service users’ health was deteriorating and she was being appropriately cared for in bed. However, their privacy may have been compromised by staff propping the door open and them sharing a room with another service user, due to the location of the room on the ground floor. The two double bedrooms continue to be without privacy screens. District Nursing staff attend the home to provide health care to a number of service users. Staff stated that areas identified by district nursing staff to the home are appropriately received and acted upon. The Grange DS0000008556.V253401.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 15 Service users are not facilitated to take part in activities and occupation at the home. There are choices available to service users at mealtimes. EVIDENCE: Service users do not routinely go out of the home unless with their own relatives. The Statement of Purpose clearly states that the home “provides a range of social and recreational activities both within the home and outside by arrangement”. Service users should be provided with opportunities to go out of the home. The home needs to be proactive in its commitment and efforts to stimulate service users and provide activity inside and outside the home. Some service users were observed sitting in the lounge for long periods, with no opportunities for mental or physical stimulation. Relatives and friends were observed visiting their cared for service users at the inspection. Visitors said they could visit at anytime and stayed as long as they wished. A service user said their relative takes them out and another service users commented that visitors could visit in the lounge or in bedrooms. The Grange DS0000008556.V253401.R01.S.doc Version 5.0 Page 14 A record is maintained of the food served so that a judgement can be made if the diet is satisfactory. On a couple of occasions, the teatime meal was not recorded. The cook said that the home is to have menus, which are to be displayed. Currently, the cook plans and prepares meals as she sees fit. Service users had mixed views about the meals served at the home, comments ranging from “good” to “alright”. When asked how they would like the meals to change, service users did not know. The cook said service users have been involved in the menu, choosing traditional foods. The Grange DS0000008556.V253401.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Systems are now in development to safeguard service users. EVIDENCE: A complaints record is now in place and details comments and complaints received by the home. The record details the investigation undertaken and the outcome. The home is to use the complaints book as part of their quality assurance checks to develop the service provided at the home. A number of staff have attended training in adult protection issue. The remaining staff group, the acting manager and deputy are scheduled to attend this training in forthcoming months. The abuse policies and procedures continue to need development. Reference should be taken from recognised publications and the local authority’s adult protection procedures and protocols to assist in this development. The Grange DS0000008556.V253401.R01.S.doc Version 5.0 Page 16 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, 21, 23, 24, 25 & 26 The environment does not promote the safety, security, comfort and respect of service users. EVIDENCE: Despite some improvements in attempting to promote the appearance of the home, it continues to look shabby. The acting manager said it is her intention to decorate the lounge and conservatory and fit new carpets. This is very much needed. A couple of service users’ bedrooms have had new curtains, which are an improvement, and also a number of service users’ bedrooms have had new wardrobes and drawers. The remainder were described to be in hand. There was evidence of broken furniture within service users’ bedrooms. The carpets are stained, old and worn. The service users’ bedrooms do not contain seating for two people. The Grange DS0000008556.V253401.R01.S.doc Version 5.0 Page 17 The home was clean and free from odours. Service users were complimentary about the skills of the housekeeping team and said the home was always clean. From observation it was evident that service users were not provided with suitable furniture on which to place cups and saucers when having a drink in the lounge areas. The wallpaper is peeling away from the ceiling in the lounge, this has been the case for some considerable time. The conservatory is situated at the front of the house. Service users who smoke use this area. At inspection, 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 conservatory. Mechanical air extraction must be provided to promote the comfort of service users who do not smoke. There are six toilets in the home, three of which are separate to the bathing facilities. There are four bathrooms, one of which provides an assisted bath. There are no en-suite facilities within service users’ bedrooms. The acting manager said one bathroom was now used as a storeroom. If this is the case, service users need to be safeguarded and action taken by the home to ensure service users do not, in error, go into this 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. 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 Grange DS0000008556.V253401.R01.S.doc Version 5.0 Page 18 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 Employment practices are not robust and compromise the safety of service users and staff. Staff training needs are not met. EVIDENCE: One service user said the two staff on duty were “wonderful and everything is organised and done” and that she felt “safe when they were on duty”. Two staff were on duty providing care to service users, the cook and two housekeepers. The sleep-in staff member stayed on duty cooking breakfast until the arrival of the cook. The sleep-in does not have food hygiene training. The cook, acting manager and deputy have recently completed this essential training and await certification. There are no staff employed at the home to undertake laundry duties. Care staff were undertaking laundry and reducing the time for direct care. The duty roster now details all that is required in relation to the staff on duty. Advice was given to the acting manager that her hours must be accurate when on the roster. The Grange DS0000008556.V253401.R01.S.doc Version 5.0 Page 19 Examination of staff files identified that Criminal Record Bureau checks had not been obtained for a newly appointed staff member, no record was provided that a POVA check had been undertaken prior to the staff member commencing employment. One staff member who has been employed for some time did not have confirmation of a CRB check being undertaken. Examination of a recently appointed staff member’s file confirmed that a job application had been completed and two references were in place. There was no evidence that an interview had taken place. Contracts of employment were not on file, nor were job descriptions. The registered person said that all staff had received job descriptions. Staff were not aware of having a written contract of employment. The majority of staff were described to have completed the induction and foundation training to care skills specifications. Again, the majority of staff have undertaken moving and handling training, with one staff being identified on the inspection not to have had this training. The acting manager said she had undertaken the training and she was assessing the skills of the staff team. It is her intention to ask staff to complete a questionnaire regarding moving and handling after which certificates are to be produced. A list of training events and seminars was not available. This would help the acting manager to see at a glance what training had been undertaken and the dates, which would help to plan future training. Currently, this information is contained in individual staff files once the certificate arrives. All staff have had one to one supervision with the acting manager and these sessions are recorded. The acting manager said that she had undertaken a number of development supervisions with specific members of the staff team. One staff member has enrolled to undertake NVQ level 2 training with a further staff member reported to be interested in taking this forward. Fifty percent of the care staff team should have NVQ level 2 training by December 2005, it is not evident how this is to be achieved. Comments have been received regarding staff smoking outside on the front doorstep. The staff are not permitted to smoke inside the home. The registered person said they had given some thought to this matter and are thinking through the best option to address this. The Grange DS0000008556.V253401.R01.S.doc Version 5.0 Page 20 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, 32, 33, 36, 37 & 38 Management systems and health and safety practices have improved but still require further development. EVIDENCE: The acting manager attended an interview with the Commission for Social Care Inspection in June 2005 for registration as manager; she is to have a second interview in the months following this inspection to assess her “fitness” to be the manager at the home. The inspector has been informed previously by the registered person of his discussions with specific service users regarding the care and support that they receive. The Grange DS0000008556.V253401.R01.S.doc Version 5.0 Page 21 Some service users are not able to articulate their views and feelings. This would be an opportunity for the registered person to involve and include representatives/relatives or advocates to ensure that their service users’ care or their observations are in keeping with good practice. No records are maintained regarding the described discussions with specific service users. Examination of the accident book identified two accidents recorded in March and September 2005. 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, however the frequency of recorded accidents would mean that this is not a priority when there are many areas for improvement. The Regulations indicate that all accidents, falls and incidents be recorded. Examination of care files identified a service user being found on the floor, this detail was not recorded as required. Examination of the records of fridge and freezer temperatures identified that they had not been completed daily, as required by Food Hygiene regulations. Staff were observed filling them in after the event. The hot food probe temperatures should be taken daily to ensure food is cooked through and to minimise the risk of food poisoning, this activity was not always recorded. 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. One of the fire doors leading from the home has a lock fitted, the access arrangements were not discussed on the inspection, a padlock was on this door. To ensure the safety of service users, advice needs to be sought from the fire authority regarding this matter. Risk assessments relating to working practices at the home have yet to be drawn up. The registered person should carry out risk assessments for all working practice 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.V253401.R01.S.doc Version 5.0 Page 22 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 1 1 2 X X 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 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 x 2 X 2 2 2 2 STAFFING Standard No Score 27 1 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 2 2 X X 2 2 1 The Grange DS0000008556.V253401.R01.S.doc Version 5.0 Page 23 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 31/12/05 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 timescale of 28/02/05 not met). The registered person must 31/12/05 ensure that a contract or terms and conditions are provided to all service users by the home and a copy signed by the service user or their representative is maintained on file. (Previous timescale of 30/06/05 not met). The registered person must 31/12/05 ensure that an assessment is undertaken for all service users prior to their entering the home and this assessment is available for the purpose of regulation. (Previous timescale of 30/06/05 not met). The Grange DS0000008556.V253401.R01.S.doc Version 5.0 Page 24 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 Timescale for action 31/12/05 5 OP9 13(2) 6 OP12 16(2)(m) 7 OP15 16(4)(13) 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 timescale of 30/06/05 not met). The registered person must 31/12/05 ensure that a policy is developed which covers the storage, administration and recording of homely remedies. (Previous timescales of 31/03/05 and 30/06/05 not met). The registered person must 31/12/05 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 and 30/06/05 not met). The registered person must 31/12/05 ensure that the home has a menu, which provides alternative meals. (Previous timescale of 30/06/05 not met). The Grange DS0000008556.V253401.R01.S.doc Version 5.0 Page 25 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 OP15 Regulation 18(1)(c) Requirement Timescale for action 31/12/05 9 OP18 13(4), 13(6), 37 10 OP19 16(2)(c) 11 OP20 23(2)(n) (p) The registered person must provide staff responsible for food preparation with training to enable them to safely prepare meals for service users. (Previous timescales of 31/03/05 and 30/06/05 not met). The registered person must 31/12/05 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 and 30/06/05 not met). The registered person must 31/12/05 replace the carpets in the lounge and conservatory. (Previous timescales of 31/03/05 and 30/06/05 not met). The registered person must 31/12/05 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 and 30/06/05 not met). The Grange DS0000008556.V253401.R01.S.doc Version 5.0 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. 12 Standard OP21 Regulation 23(2)(p) Requirement The registered person must install light shades to light fittings in all bathrooms and toilets. (Previous timescales of 28/02/05 and 30/06/05 not met). The registered person must replace the broken drawers within service users’ bedrooms. (Previous timescales of 31/03/05 and 30/06/05 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 and 30/06/05 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 and 30/06/05 not met). Timescale for action 31/12/05 13 OP24 23(c)(b) 31/12/05 14 OP27 18 31/12/05 15 OP28 18 31/12/05 The Grange DS0000008556.V253401.R01.S.doc Version 5.0 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. 16 Standard OP29 Regulation Schedule 2 Requirement The registered person must ensure that the selection and recruitment procedures are in place to safeguard service users and include satisfactory enhanced CRB disclosure checks prior to staff commencing employment. (Previous timescales of 30/09/04, 28/02/05 and 30/06/05 not met). 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 and 30/06/05 not met). The registered person must take advice from the fire officer regarding the placement of the padlock on the emergency exit from the building, taking on board his recommendations regarding this matter. The registered person must ensure that all accidents, incidents, falls and occurrences are recorded in the accident book. Timescale for action 31/12/05 17 OP33 24 31/12/05 18 OP38 23.4 31/12/05 19 OP38 Schedule 3 31/12/05 The Grange DS0000008556.V253401.R01.S.doc Version 5.0 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. 20 Standard OP38 Regulation 16(2)(i) Requirement The registered person must ensure that freezer temperatures and hot probe temperatures are recorded at the regularity as defined within food hygiene regulations. (Previous timescale of 30/06/05 not met). Timescale for action 31/12/05 The Grange DS0000008556.V253401.R01.S.doc Version 5.0 Page 29 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. The registered person should maintain a record of the content of service user/representative meetings/discussions at the home available for inspection. The registered person should carry 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. 3 4 OP18 OP24 5 OP24 6 7 OP29 OP29 8 9 10 OP30 OP33 OP38 The Grange DS0000008556.V253401.R01.S.doc Version 5.0 Page 30 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. 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