Inspection on 20/07/06 for The Grove

This inspection was carried out on 20th July 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 Grove 11/07/07

The Grove 30/12/05

The Grove 04/08/05

The Grove 24/01/05

The Grove 27/09/04

The Grove 02/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Grove 48 Lode Lane Solihull West Midlands B91 2AE Lead Inspector Karen Thompson Unannounced Inspection 20th July 2006 09:00 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 Grove DS0000004519.V305234.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 Grove DS0000004519.V305234.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Grove Address 48 Lode Lane Solihull West Midlands B91 2AE 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) 0121 705 3356 0121 713 2110 grovesolihull@yahoo.co.uk The Grove Residential Home (Solihull) Mrs Lyndon Green Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places The Grove DS0000004519.V305234.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30 December 2005 Brief Description of the Service: The Grove is a mid Victorian building with an extension added. It consists of three storeys and is located on the main route to the Coventry Road from Solihull. Solihull town centre is easily accessible from the home. The home is near places of worship and is on a main bus route. There are two main lounges, a small visitors room and a dining room. The home caters for 30 older adults and all bedrooms are of single occupancy. Access for wheelchairs is available with ramps at the front and rear of the building. The homes garden is accessed by a ramp from one of the main lounges. The Grove DS0000004519.V305234.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The report findings are based on an unannounced fieldwork visit, which incorporated one anonymous concern investigation. The area of concern was in relation to medication management. This has been looked at under standard 9. Information was gathered from a number of sources: a tour of the building, examination of records and documents, talking to residents, relatives, staff members and managerial staff, direct and indirect observation. What the service does well: What has improved since the last inspection? Recruitment practice has improved ensuring that this is robust and protects residents. The management team and staff have been reviewing nutrition and looking at how they can ensure individual choices and preferences can be accommodated to maintain good nutritional health. Staff supervision has increased ensuring staff are adequately supported to meet the needs of residents. The Grove DS0000004519.V305234.R01.S.doc Version 5.2 Page 6 Documentation in a number of areas has improved so that the staff are able to audit, monitor and demonstrate that residents wellbeing is being promoted and protected. 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 Grove DS0000004519.V305234.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 Grove DS0000004519.V305234.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3.4.5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Assessments, care planning and deliver of care has some weakness which need to be addressed to ensure residents have a service that meets their individual needs. EVIDENCE: The Registered Manager and deputy carried out the Pre-admission assessments, which are detailed but not always comprehensive, signed or dated. Following admission to the home staff draw up a care plan. Seventeen members of staff have received training in relation to challenging behaviour One residents file sampled demonstrated that whilst staff do respond to needs they had not been proactive in monitoring and anticipating needs in a number of instances for this particular resident. Whilst the inspector witnessed good interaction between staff and residents it must be acknowledged that recent research has shown that 75 of aggressive outbursts by residents are due to poor staff interaction. Language used in some care documents could The Grove DS0000004519.V305234.R01.S.doc Version 5.2 Page 9 sometimes be described as controlling. Staff need to be aware of what triggers challenging behaviour but also how their responses can affect outcomes. This will ensure that staff are not just reacting to situations but have the skills to be proactive and limit or prevent such occurrences. The home has a number of residents with cognitive impairment, whose condition is outside their present registration category and which was discussed with the Care Manager during the inspection. Mental health assessments are not taking place for residents admitted to the home, this is an important baseline measurement to monitor changes. Plans to extend the home were also discussed during the inspection along with the possibility of a change of registration. A number of staff have received an introductory training to dementia care. The possibility of staff doing a more in-depth dementia awareness course was also discussed with the Care Manager during the inspection. Care plans did not demonstrate how residents with dementia would have their specific needs met in relation to this condition. Care planning needs not just to focus on difficulties but strengths and abilities and how these can be utilised to the full. Records demonstrated that residents were invited to visit the home prior to admission. The home needs to ensure that potential residents are written to by the home following pre admission visits and assessment stating whether the home can or cannot meet their needs. This letter should be kept on the residents file. The Grove DS0000004519.V305234.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9.10.11 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The quality of care planning for the majority of residents was variable which could potentially lead to poor outcomes for residents. There was evidence of good multidisciplinary working taking place on a regular basis but the home was not assessing all health needs and this could potentially lead to poor outcomes for residents. Overall the medicine management is good with the exception of the one incident. EVIDENCE: The quality of care planning recording was mixed. The daily records recording has improved but the care plans were not always being reviewed when residents needs changed. Care planning records could be detailed but they were also found to lack clarity and detail on how to deliver care in some instances. Documentation was not always being signed or dated by staff and residents or their representatives. Care plans did not contain assessment of specific to falls, skin integrity or self medication. A format for self medications risk assessment was sent to the home post-inspection. A number of assessments were taking place for The Grove DS0000004519.V305234.R01.S.doc Version 5.2 Page 11 example nutrition, manual handling and falls but their findings were not always being linked into the Care Planning process or used to inform care practice. The Care Manager is reviewing the format used for care planning and initial documentation and recording seen by the inspector appears to be an improvement on what is being used at present. Residents’ files demonstrated that a variety of multi-disciplinary team members were visiting the home and referrals were being made. During the inspection a General Practitioner visited the home and a good professional working relationship was observed. The home on the whole demonstrated many good practices for the safe handling of medicines and staff have a good understanding of the clinical conditions and what the medicines are for. The administration of medicines was fully documented and reflected practice the majority of times. The concern raised in relation to medication administration for one resident was found not to meet the standard and regulations and was referred to Social Care and Health under adult protection procedures. The inspector observed good interaction between staff, residents and relatives. Both residents and relatives were spoken to in an appropriate manner by staff. Staff were observed not to lock the shower door when assisting residents with personal hygiene needs. By not doing this they run the risk of the residents dignity being compromised with other residents or members of staff entering the room. A communal basket in the laundry contained stockings. This issue with be explored further at the next inspection as clothing should be returned to residents’. During the inspection one resident died. Staff conducted themselves in a dignified and respectful manner and clearly saddened by this residents death. The Grove DS0000004519.V305234.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12.13.14.15 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Social and recreational interests and needs are viewed as a important aspect of care for residents and staff strive to meet these via a variety of processes. Choice and control was not well recorded but residents and relatives stated this was taking place and they were happy with the service. The home endeavours to meet all aspects of residents nutritional needs ensuring the well being of residents nutritionally. EVIDENCE: A variety of activities were available for residents including bingo, shopping, Ascot race day (at the Grove), visits to the theatre and local zoo. The inspector was shown the celebration book during the fieldwork visit which contained numerous photographs of the activities that had taken place. Relatives and residents commented that they were happy with the activities provided at the home. One relative commented that they had been informed that if they wish to part take in any events in or outside the home they were welcome to join in. Visitors were observed around the home thoughout the day. The Grove DS0000004519.V305234.R01.S.doc Version 5.2 Page 13 Two residents chatted to during the fieldwork visit stated that they went to bed and got up when they wanted. During the fieldwork visit the country had been experiencing the hottest July in recorded history. The Care Manager and her team had responded to this challenge by reviewing the menus and the way food is provided. There was an impressive array of cold drinks and ice lollies available within the home for residents. One relative commented that as soon as they arrived a drink was offered and this continued thoughout their visit and had been given lunch. Discussions during the visit and post inspection with the Care Manager revealed that they had been looking at the practice of meal and food delivery and how this could be tailored to ensure individual needs, likes and preferences could be met with in a large setting. The home was looking at increasing the type of finger food available to residents. The inspector observed that the residents’ evening meal was in one instance a cold buffet type meal which the residents were able to eat later in the cool of the day. The Care Manager and her team were also looking at a wider range of food suppliers. Residents’ comments in relation to meals was positive. The Grove DS0000004519.V305234.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16.18 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Systems are in place to ensure that Residents are protected and concerns listened to and for the majority of the time these are dealt with in a sensitive and professional manner. EVIDENCE: The complaint procedure meet the standard. There have been no complaints received by the home since the previous inspection. Part of the fieldwork activity was in relation to concerns raised about medication practice which is looked at under that particular standard. The home’s policy and procedures required minor amendments to ensure that they linked into the local multi-agency guidance and this was completed during the inspection. The home’s restraint and handling aggression policy has been reviewed. Seventeen of the twenty seven members of care staff have received training in managing challenging behaviour. Training for the remaining staff is required. Recent incidents within the home suggest that staff need to be debriefed via the supervision process to see if on reflection, they might have dealt with the situation differently or spotted triggers that precipitated this behaviour earlier. The Grove DS0000004519.V305234.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19.20.21.22.23.24.25.26 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The standard of environment provides residents with an attractive, safe and comfortable and homely place to live. Residents’ private accommodation is suited to their needs and personalised according to their tastes and preferences. EVIDENCE: The home was found to be clean and free of odours. The garden is accessible to residents and a variety of garden furniture was available along with a gazebo offering shading. Residents and relatives were observed throughout the day accessing the garden. Since the previous visit the server area has been upgraded. The home is looking to extend and enhance the home’s facilities. The plans have been submitted for planning permission. At present there is no date for starting the extension. In view of this the home needs to review its sluicing facility as at present commode pots are being washed manually and not in a pot disinfector. The Grove DS0000004519.V305234.R01.S.doc Version 5.2 Page 16 A number of external areas of the home were noted to be in a poor state of repair, one window sill was observed to be rotten. A survey of the structural integrity of the home has been carried out and a number of areas have been highlighted as requiring attention. All bedrooms are single. The majority of rooms did not have ensuite facilities but all rooms had a hand washbasin. One ensuite facility had plaster missing from the wall by the sink facility. Bedrooms were individualized with residents’ own personal possessions. Residents are offered keys to their bedroom door. Aids, hoists and assisted toilets and baths are available though out the home. Hot water outlets are tested monthly and are fitted with thermostatic control values. The Care Manager was advised to review the risk assessment in relation to the testing of hot water outlets where residents could be totally immersed such as showers and baths. Control measures are in place for preventing the risk of Legionella. Staff were observed to be wearing the correct protective clothing for the tasks they were performing. The Care Manager informed the inspector that new commode chairs had been purchased. The Grove DS0000004519.V305234.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27.28.29.30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are selected by a robust recruitment procedure thus protecting residents. The home is committed to training its staff and thus ultimately meeting residents’ needs. The home employs ensures sufficient numbers of staff are available to meet residents needs. EVIDENCE: The rotas supplied demonstrated that staffing levels were evenly spread throughout the week and were sufficient to meet the needs of residents. The home employs auxiliary staff with regard to domestic, laundry and catering staff. Discussions with the Care Manager revealed that over seventy five percent of staff were trained to either NVQ2 or 3 and several other staff were undertaking this qualification. The home had a good recruitment procedure to ensure that all staff are recruited in line with current guidelines. A sample of staff files were inspected and all had satisfactory police checks undertaken. An impressive array of training was taking place for all staff in the home. The Care Manager has a training matrix which was viewed during the inspection. The inspector received evidence post inspection that identifying lapses in mandatory training that had taken place. The home has not implemented the The Grove DS0000004519.V305234.R01.S.doc Version 5.2 Page 18 new Skills Council induction training and this was discussed with the Care Manager. The Grove DS0000004519.V305234.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31.32.33.35.36.38 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The home is well managed and run for the benefit of the residents. The health, safety and welfare of residents and staff are generally promoted and protected. EVIDENCE: The Care Manager was able to demonstrate an understanding of and an individual approach to meeting both residents and their relatives needs. The Care Manager has been in post for many years and is appropriately qualified to run the home. The Commission receives Regulation 26 visits from a member of the management committee on a monthly basis allowing the home to be monitored in between visits. The Care Manager is working with a member of The Grove DS0000004519.V305234.R01.S.doc Version 5.2 Page 20 the Committee in monitoring the fabric and furnishing of the home by doing monthly audits. The home has a quality assurance system in place consisting of internal audits, regular residents and staff meetings. There were twenty nine questionnaires sent out to visitors in November 2005 and responses were, in the main, positive about the service. The Care Manager and a Committee member carry out regular audits together looking at the decoration, furniture and fittings. Written records and receipts of a sample of residents’ personal money were seen. All money was kept in a secure place and all documentation was accurate. Staff supervision was taking place and if the frequency of supervision continues these will be occurring a minimum of six times in twelve months. Health and safety at the home was generally well maintained. The home seeks independent advice about health and safety issues. The fire risk assessment has been reviewed since the previous inspection. Fire alarm testing and servicing was taking place. Evidence of hardwiring electrical safety was received by the Commission post-inspection. Hoist and lift servicing and maintenance was taking place. Gas equipment maintenance and servicing was taking place on a regular basis. The gas cooker was only partially working and due to its age could not be repaired but needed replacing. The kitchen staff wash the catering equipment they use by hand. All utensils used in catering needs to be washed at 83c, but at present this is not being achieved. Residents crockery is washed in a dishwasher where these temperatures can be achieved. The home needs to review how utensils used by the catering department can be cleaned at the correct temperature and to ensure the appropriate systems are put in place to achieve this. The laundry door is not always being locked when staff are not present. The inspector found the laundry door to not locked on arriving at the home. There has been an incident were a resident with cognitive impairment was found in the laundry by staff and this is concerning. The Grove DS0000004519.V305234.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 2 2 2 x 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 3 3 3 3 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 3 x 2 The Grove DS0000004519.V305234.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 OP5 Regulation 14(1) Requirement The Registered Person must ensure that a comprehensive pre admission assessment is carried out and following this potential residents are notified in writing whether the home can meet their needs. A copy of this letter should be kept on the residents file Timescale for action 30/10/06 The Grove DS0000004519.V305234.R01.S.doc Version 5.2 Page 23 2 OP4 OP7 18(1)(a) The Registered Person must 30/11/06 review staff training in regards to dementia awareness and care. The Registered Person must ensure that assessment include mental health where it is identified as a need. The Registered Person must ensure that care planning for those residents with cognitive impairment is based on a person centred approach to ensure strengths as well as weakness are acknowledged. The Registered Person must ensure that staff receive training and guidance in managing aggressive behaviour. (Outstanding requirement 4 Aug 2005) The Registered Person must ensure that all service users’ care plans are based on comprehensive assessments and cover all aspects in relation to health, personal and social care. (Outstanding requirement 24 Jan 2005). The Registered Person must ensure that care plans are reviewed and updated frequently to reflect changing needs and current objectives for health and personal care. This process must involve consultation with the service users and or representative. (Outstanding requirement 24 Jan 2005) 3 OP7 15(1) 30/11/06 4 OP7 15(2)(b, c) 30/11/06 The Grove DS0000004519.V305234.R01.S.doc Version 5.2 Page 24 5 OP7 13(4)(b,c) The Registered Person must ensure manual handling assessments are linked into care plans. (Outstanding requirement 4 Aug 2005) The Registered Person must ensure that nutritional and falls assessments are linked into the care planning process. The Registered Person must ensure that a falls risk assessment is carried out and appropriate action taken. (Outstanding requirement 4 Aug 2005) The Registered Person must also ensure that an assessment is carried out in regards to skin integrity for all residents. A system must be installed to check all the prescriptions prior to dispensing and the dispensed medicines and MAR charts received into the home. All medicines that have been discontinued by the doctor must be deleted from the MAR chart Undertake staff drug audits before and after a medicine round to confirm staff competence in medicine management. Appropriate action must be taken when discrepancies are found The Registered Person must ensure that staff promote and maintain the dignity of residents at all times. Shower room doors should be locked when residents are accompanied by staff to ensure residents dignity is maintained. 30/11/06 6 OP8 12(1) 30/11/06 7 OP9 13(2) 30/09/06 8 OP9 13(2) 30/09/06 9 OP10 18(1) 12(1) 30/09/06 The Grove DS0000004519.V305234.R01.S.doc Version 5.2 Page 25 10 OP19 23(2)(b) 11 OP25 12 OP26 13 OP30 14 OP38 The Registered Person must submit an action plan as to when the external structural fabric will be replace or repaired as identified in their survey. 13(4)(a)(c The Registered Person must ) review their testing and monitoring of hot water outlets were total immersion is possible. 13(3) The Registered Person must 16(2)(j) ensure that sluicing facilities within the home include a pot disinfector. 12(10(a)( The Registered Person must b) review its induction programme for new staff in line with Skills Council guidance 23(2)© The Registered Person must forward evidence that a new gas cooker has been purchased. 13(4) 13(4) The Registered Person must ensure that kitchen utensils and equipment are washed at 83c. The Registered Person must ensure that staff adhere to ensuring the laundry door is locked when no staff are present. 30/09/06 10/09/06 31/01/07 30/11/06 30/09/06 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 OP9 Good Practice Recommendations Protocols for when required medication should be written. (Carried forward not inspected on this occasion). The Grove DS0000004519.V305234.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Grove DS0000004519.V305234.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!