Inspection on 15/05/07 for The Grange Chertsey (2002) Ltd

This inspection was carried out on 15th May 2007.

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

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

Other inspections for this house

The Grange Chertsey (2002) Ltd 23/01/06

The Grange Chertsey (2002) Ltd 02/09/05

The Grange Chertsey (2002) Ltd 09/12/04

The Grange Chertsey (2002) Ltd 17/06/04

The Grange Chertsey (2002) Ltd 23/02/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE The Grange Chertsey (2002) Ltd The Grange Ruxbury Road St Anne`s Hill Chertsey Surrey KT16 9EP Lead Inspector Pauline Long Unannounced Inspection 15th May 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Grange Chertsey (2002) Ltd DS0000013655.V335299.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. The Grange Chertsey (2002) Ltd DS0000013655.V335299.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Grange Chertsey (2002) Ltd Address The Grange Ruxbury Road St Anne`s Hill Chertsey Surrey KT16 9EP 01932 562361 01932 560858 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) The Grange Chertsey (2002) Ltd Mrs Diana Mary McWilliam Care Home 46 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (46), of places Sensory Impairment over 65 years of age (8) The Grange Chertsey (2002) Ltd DS0000013655.V335299.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE Within the categories `OP` (OLDER PEOPLE), sixteen may be within the category DE(E) and eight may be SI(E) 23rd January 2006 Date of last inspection Brief Description of the Service: The Grange is a large older detached property set in spacious private gardens. The service provides twenty-four hour care for up to forty-six older people. There are five double bed rooms and all have en-suite facilities that include a toilet, basin and bath. There are spacious communal areas that include two lounges, two dining rooms and a bright and airy conservatory looking out onto the main gardens. The service provides a range of activities and events for residents to attend both in-house and within the local community. The fees at the home range from £416.00 per week to £675.00 per week. The Grange Chertsey (2002) Ltd DS0000013655.V335299.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 09.30 and was in the service for 5 .5 hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. Communication with some of the residents was limited, due to their communication difficulties, however body language and appearance indicated a sence of well being. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The CSCI would like to thank the residents, the owner, manager, staff and visitors for their hospitality, assistance and co-operation during the “Key Inspection” process. What the service does well: The owner, home manager and staff demonstrated an open and inclusive approach to the residents’ care. The residents benefit from a long standing staff team, some of whom who have worked in the home for several years, and this was reflected in the level of knowledge and understanding of the needs and preferences of the residents. The home promotes and encourages contact with family/friends and the local community. Residents spoken with were complimentary about the care and services provided by the home. They commented that, they always get the care and help they need, “that the care they received was good” and “that the staff are very good”. Relatives commented that the staff at the home were very professional, that they remained friendly and approachable and nothing was too much trouble. Health care professionals commented that staff were helpful, they communicate well and are very well informed about the residents’ needs. The standard of environment is good, providing the residents with a very pleasant place to live. The Grange Chertsey (2002) Ltd DS0000013655.V335299.R01.S.doc Version 5.2 Page 6 From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Grange Chertsey (2002) Ltd DS0000013655.V335299.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Grange Chertsey (2002) Ltd DS0000013655.V335299.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,5 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents are only admitted to the home following an assessment of their needs. The home does not provide an intermediate care service. EVIDENCE: The home provides a care service mainly for privately funded residents however some local authority service users can be admitted from time to time. The manager stated that following a referral and telephone discussion the prospective resident would be invited to the home for further discussion. This was evidenced in a letter of thanks from one relative. Following this visit the manager would then visit a prospective resident at their home or hospital to carry out the care needs assessment. The home would undertake a six week trial assessment to ensure that the resident’s needs could be properly met. The manager stated that if there were any areas of concern in that time then the placement would be reviewed. One resident spoken with commented that before she was admitted to the home she came for a visit to see if she would like it. One relative commented that their visit to The Grange to assess The Grange Chertsey (2002) Ltd DS0000013655.V335299.R01.S.doc Version 5.2 Page 9 whether it could meet their relative’s needs only confirmed their desire for their relative to live at the home. Four of the residents’ care needs assessments were sampled and were found to provide a comprehensive overview of the resident’s care needs, for example all daily living activities and their preferences in respect of their names, health and social care needs, spiritual needs and their likes and dislikes around activities. The Grange Chertsey (2002) Ltd DS0000013655.V335299.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ health and social care needs are well met. They are treated with respect and their privacy and dignity are promoted. Improvements are required in the care plan documentation. EVIDENCE: The resident’s care plan is incorporated into the home’s care needs assessment document, and whilst the care needs assessments were comprehensive it was not clear as to which care need had a corresponding care plan. The last page of the document had a general statement in respect of the care needs identified, however it did not provide the reader with clear instructions as to how care needs identified were to be met. Discussions were had with the manager in respect of developing these documents, in order to ensure that each identified care need had a documented corresponding care plan in place. There was evidence to suggest that the documents had been reviewed on a monthly basis. Residents and a visitor to the home commented, that, “the care they received at the home was good” and that they had access to their care plan as they were kept in their bedrooms. None of the documents sampled had been signed by a resident or their The Grange Chertsey (2002) Ltd DS0000013655.V335299.R01.S.doc Version 5.2 Page 11 representative, however all had been signed by the manager. Discussions were had in respect of gaining a resident’s or representative’s signature on the care plan or recording the reasons as to why no signatures had been obtained. It should be noted that following the site visit, the inspector was informed that the care plan format had been improved. The owner stated that the new format was completed the following day. Medication practices and procedures in respect of administration, record keeping, storage and training were sampled. Medication administration was observed and was found to be carried out in a sensitive and safe manner. The storage of medication was also found to be safe. General medication record sheets were sampled, and were found to be well documented, with no gaps in signatures noted. The staff commented that daily checks are carried on the medication record sheets and any issues noted would be addressed with the member of staff at the time. Discussions were had with the care staff about the home’s medication policies and procedures. It was evident through these discussions, that the staff had a good understanding of the policies and procedures. The manager commented, that only the senior staff who had undertaken formal training and who were competent were permitted to administer medications. Care staff confirmed this. Medication training was evidenced in the home’s training records. Throughout the inspection process, staff were observed carrying out various aspects of personal care for the residents, this support was offered in a respectful and sensitive manner. Staff were observed knocking on doors and waiting to be invited in, before entering rooms. Bathroom doors were kept closed whilst staff were attending to residents’ personal care needs. Residents and a relative commented that, all of the staff were kind and treated them with respect. A requirement and a recommendation have been made in respect of these areas. Please refer to pages 25 and 26 of this report. The Grange Chertsey (2002) Ltd DS0000013655.V335299.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People who use the service experience good quality outcomes in this area. The residents are encouraged and enabled to maintain fulfilling lifestyles in the home and contact with family, friends and the local community is promoted. Residents are encouraged and enabled to makes choices in their lives and meal times at the home are a positive and pleasant experience for the residents. EVIDENCE: The home is committed to ensuring that the residents maintain their relationships with their family and friends. Residents commented that they received visits from their families and friends. Some relatives and visitors were observed visiting the home during the site visit. The visitors to the home commented that all the staff at the home were very welcoming. There was evidence of various flyers on the home’s notice boards relating to activities and trips, for example, residents are encouraged to take part in gentle exercise classes, art and craft sessions The manager discussed a recent visit to the home from a Maori song and dance group. Several comment cards were returned to the Commission, many from relatives, some comments were made in respect of the lack of trips outside the home. However residents spoken with were happy with the activities provided in the home. Some were looking forward to the good weather returning so they could get out and enjoy the “lovely garden”. Several residents were enjoying a musical exercise class. The manager commented that this class had been very beneficial for one of the The Grange Chertsey (2002) Ltd DS0000013655.V335299.R01.S.doc Version 5.2 Page 13 residents. Some residents were observed reading the daily newspaper. Newspapers can be in large print for those residents with sensory impairment. The home encourages the residents to practice their faith and has arranged for monthly visits from one of the local churches. Residents were observed moving freely around the home, making choices as to how they would spend their day, for example, where they would spend their time and what they would like to eat and drink. The meals are freshly cooked in the home and it was positive to note, the choice of food on offer was good. Whilst the menu board related to only one main course, the residents commented that if they did not like what was on offer then the Chef would cook something else. Discussions were had with the Chef in respect of residents’ likes and dislikes. She demonstrated a good understanding of each resident’s likes and dislikes, and specialist diets for example diabetic, vegetarian and soft diets. Residents and visitors commented that the food at the home was good. One resident commented that they could have all their meals in their rooms of they so wished. Some residents required support with their meals, this support was offered in a sensitive, dignified and unhurried manner. The Grange Chertsey (2002) Ltd DS0000013655.V335299.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The residents are protected by the home’s policies, procedures and practices around concerns, complaints and protection. EVIDENCE: Three complainants have contacted the Commission with information concerning a complaint made to the service since the last inspection. These complaints were referred to the home to be investigated under the home’s complaints procedures. Two out of the three complaints were substantiated the third one was not substantiated. The manager commented that following one of the complaints the medication procedures and practices were reviewed and new procedures put in place, this evidenced that the home has an effective complaints procedure. Residents spoken with, commented, that if they had any reason to complain, they would speak with the manager. Two referrals have been made under the local authority multi agency Safeguarding Adults procedures. Meetings have been held in respect of these referrals and the issues have been resolved. Discussions were had with the staff on duty and scenarios put to them in respect of the home’s safeguarding adults and complaints procedures. Staff interviewed demonstrated a good understanding of the policies and procedures. All of the senior staff have undertaken the local authority multi-agency safeguarding adults training. Other staff members undertake the home’s in house training as evidenced in the home’s training records. The Grange Chertsey (2002) Ltd DS0000013655.V335299.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment is able to meet the changing needs of the residents, it is homely, clean safe and comfortable. EVIDENCE: The home is an older property and therefore presents the owners with challenges in respect of the constant need for updating and refurbishment. Considerable work has been undertaken in this respect since the last inspection. Improvements have been made in the bathroom facilities, three baths have been removed and replaced with walk in showers, which makes things easier for those frailer residents. Five bedrooms have been refurbished and two are undergoing refurbishment, residents commented that their rooms were lovely. It should be noted that there are five double bedrooms, and the owner stated that they were occupied by only one resident. Many areas in the home have been redecorated, providing a more pleasant environment for all. A second shaft lift has been installed which will provide residents with lift access to the 2nd floor. Building work is being carried out, and the owner The Grange Chertsey (2002) Ltd DS0000013655.V335299.R01.S.doc Version 5.2 Page 16 stated, that when it is completed (by December 2007) will include 19 further bedrooms, 2 new residents’ lounges, 2 new lifts that will service all three floors, and the completion of all refurbishment of the home. Discussions were had with the residents and visitors in respect of the building works and any disruption caused. They commented that the disruption was barley noticeable, and whilst there was some dust and noise it was not a concern. They were looking forward to the end of the year and the completion of the project. They commented that they had been kept informed throughout as to the progress. It was noted that posters were placed throughout the home informing all of the progress and next stages. One relative commented that the facilities at the home were second to none. All areas of the home where building works were taking place had been made inaccessible to the residents, ensuring their safety. The home is clean and hygienic with good systems in place to prevent the spread of infection. The Grange Chertsey (2002) Ltd DS0000013655.V335299.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service. Improvements are required in the recruitment practices to ensure that two written references are in place for all staff. EVIDENCE: Staff files sampled and work based observations evidenced that the home employs a diverse staff group. On the day the staffing levels were adequate for the dependency levels of the residents. Staff commented that the home was very seldom short staffed and that there was minimum agency usage as evidenced in the staffing rotas and the pre inspection questionnaire. As discussed earlier in this report, the home is being extended further to provide 19 more bedrooms. Both the manager and owner stated that the staffing levels will be increased to reflect the increase in residents and the overall size of the building. The aim is to have a team of staff on each floor. Residents and relatives commented that all of the staff were kind, helpful, knew what they were doing and good at their jobs and that nothing would be achieved at the home without the dedication of all the staff who work there. Health care professionals commented that staff were helpful, they communicate well and are very well informed about the residents’ needs. One care manager commented that the home responds well to all of the residents’ needs regardless of age, disability gender and culture. The Grange Chertsey (2002) Ltd DS0000013655.V335299.R01.S.doc Version 5.2 Page 18 The home’s recruitment practices were sampled, and were found to be satisfactory. Three staff files were sampled and all had the required documentation in place, with evidence of CRB (Criminal Records Bureau) or POVA (Protection of Vulnerable Adults) checks. One of the files did not have a reference from the member of staff’s previous employer, another one had one written reference and one verbal reference. There was no evidence to indicate the verbal reference had been followed up with a written reference. Discussions were had with the manager and owner in respect of these shortfalls. Discussions were also had in respect of the retention of CRB disclosures and the need to refer to the guidelines in this respect. The day after the site visit discussions were had with the manager in respect of the verbal reference. She was unable to confirm that they had received a follow up written reference. The manager confirmed that if the situation were to arise in the future, she would ensure that all staff had two written references. Therefore no requirements have been made in this respect. Discussions were had with staff, who, talked about their job roles and responsibilities. Work based observations, evidenced competent and confident staff carrying out their various tasks. Staff training is given a high priority in the home and staff discussed some of the training they had undertaken. Training records demonstrated that statutory and various current good practice training had been undertaken since the last inspection for example: promoting incontinence, being positive under pressure, dementia care, risk assessment and care planning. The home is proactive in promoting NVQ (National Vocation Qualifications), and is working towards the National Minimum Standard recommendation of having at least 50 of care staff with NVQ2 or above. The manager commented that training courses were arranged to ensure that all staff have an opportunity to attend, for example; training courses timed in the evenings to enable the night staff and staff with carer responsibilities to attend. The training records did not evidence any specific training in respect of Equality and Diversity, however the manager and staff commented that Diversity issues are discussed during the staff induction training, on a day- to- day basis and in the NVQ modules. Care staff discussed various diversity issues in respect of the residents, for example residents rising and going to bed when they please, residents’ faith needs being addressed, and residents’ dietary needs being considered. The Grange Chertsey (2002) Ltd DS0000013655.V335299.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,37,38 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The residents benefit from an open and inclusive management approach to the running of the home and their views are listened to. EVIDENCE: The registered manager has worked at the home for 3 years. She is a registered nurse and has recently achieved the Registered Managers award. All of the residents and staff spoken with commented that the manager has a hands on approach to the residents’ care, this was evidenced on the day as the manager was observed helping out with carer responsibilities. A visitor to the home commented that the manager was very helpful and was always available if someone wished to speak with her. The home actively seeks the views of the residents. Resident association meeting are held, where residents are encouraged to express their views. The The Grange Chertsey (2002) Ltd DS0000013655.V335299.R01.S.doc Version 5.2 Page 20 home has obtained and is in the process of implementing a “Putting Service Users First” quality assurance programme. To date they have not sent any service user surveys out to residents or other stakeholders. The manager was confident that residents’ views are actively sought on a daily basis as she spends time out on the floor and meets with all of the residents. Residents spoken with commented that the manager was always around. The inspector sampled a considerable number of letters of thanks received at the home. Discussions were had with the manager around residents’ personal monies. She stated that resident’s families/representatives had responsibility for resident’s monies. Discussions with the manager and care staff indicated that one to one staff supervision meetings were held. However the manager commented that it was a challenge to achieve the required number per year. She stated that some of the senior care staff were going undertaken a training course in respect of staff supervision in order to ensure the required number of meetings are undertaken. The staff commented that they regularly work together with the manager and other senior staff and have regular discussions around residents’ needs. They also commented that they had formal one to one meetings with a manager. There was some evidence on the managers IT system. Discussions were had with the manager in respect of the staff being issued with copies of their supervision records. The staff commented that, they are also expected to attend regular team meetings. The most recent team meeting was held on 30th April as evidenced in the minutes of the meetings. Health and safety checks are routinely carried out at the home. The owner walks the floor on a daily basis in order to identify and address any issues which may arise. Records evidenced that health and safety are given a high priority at the home. The Grange Chertsey (2002) Ltd DS0000013655.V335299.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 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X 3 X X 3 STAFFING Standard No Score 27 4 28 3 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 3 X 4 The Grange Chertsey (2002) Ltd DS0000013655.V335299.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 12(10(a) 15(1) Requirement Care plans must be further developed to ensure that all care needs identified have a corresponding care plan in place. To ensure that all staff are aware of how identified needs are to be appropriately met. Timescale for action 15/07/07 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 OP7 Good Practice Recommendations The manager could consider documenting on the care plans the reasons for residents/representatives not providing their signatures. The Grange Chertsey (2002) Ltd DS0000013655.V335299.R01.S.doc Version 5.2 Page 23 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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Grange Chertsey (2002) Ltd DS0000013655.V335299.R01.S.doc Version 5.2 Page 24 - 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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