Care Home: Moorlands Grange

What has improved since the last inspection? Quality assurance surveys are carried out annually to reflect the views of the service, and improve the service to people living at the home. The results are also displayed in the home for people who live there and visitors to see. The supervision of staff has commenced to ensure that staff are meeting their full potential and the needs of people in their care. What the care home could do better: The organisation of the care plans needs to be clear to ensure that anyone reading them can understand them, and staff should ensure that the daily recording of the care given fully reflects the identified needs of the person. Activities need to be made available on a daily basis, and arrangements made for people to take part.Moorlands GrangeDS0000067432.V375163.R01.S.docVersion 5.2Page 8 Key inspection report CARE HOMES FOR OLDER PEOPLE Moorlands Grange Spruce Drive Netherton Huddersfield HD4 7WA Lead Inspector Karen Summers Key Unannounced Inspection 28th April 2009 08:30 DS0000067432.V375163.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Moorlands Grange Address Spruce Drive Netherton Huddersfield HD4 7WA 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) 01484 222351 01484 222352 www.kirklees.gov.uk Kirklees MC Mrs Mary Frances McCullagh Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (20), Physical disability (20) of places Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP, maximum, number of places 20 Physical disability Code PD, maximum number of places, 20 The maximum number of users who can be accommodated is 40 2. Date of last inspection 27th April 2007 Brief Description of the Service: Moorlands Grange was built in 2006. It is a two-storey care home that is owned by Kirklees Adult Services Council and is registered to provide accommodation and care for a total of forty people; twenty people who are experiencing issues related to the ageing process, twenty places for people with a physical disability. Out of the total of forty, twenty places are for people who require intermediate care. The intermediate care services are on the first floor in The Oakmoor Suite and are run by a partnership between Kirklees Adult Services and Health Services. The aim is to make sure that people who would otherwise be admitted to hospital remain as independent as possible and regain or adapt their day-today living skills. The maximum stay on this unit is 6 weeks. The long-term services are on the ground floor in The Hawthorne Suite where long-term care is provided for people who are unable to live safely and independently at home. All bedrooms are for single occupancy and are equipped with en-suite facilities. Communal areas are spacious and comfortable and are decorated and furnished to a high standard. The establishment is situated in a residential area of Netherton and the main road through the centre of the village has a good bus route to Huddersfield Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 5 Town and the village of Meltham. Long-term peoples’ fees are £108.10 - £527.44 per week. People who use the service do not pay for intermediate care. Items not covered by fees include hairdressing, newspapers, toiletries, WRVS sweet trolley, phone calls, postage of personal mail, private chiropody, optician and the dentist. Information about the home and the services provided are available from the home in the statement of purpose and service user’s guide. Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two star. This means the people who use this service experience good quality outcomes. This report refers to an inspection, part of which included an unannounced visit, on the 28th April 2009, commencing at 8.30am, and the length of the inspection was 7.25 hours. Although the manager was there on the day of the visit, she has been seconded for a few weeks to help with other homes within the group. She confirmed that she proposed to return to the home in the near future. The deputy manager is in the short term, there on a day to day basis and is supported by the manager and other senior staff. There were 39 people living at the home on the day of the visit. As part of the inspection in order to provide information to help us form judgments about the quality of the service, the manager was asked to complete an annual quality assessment (AQAA) document. This she did, and the document provided the Care Quality Commission (CQC) with a lot of information about the way the home is run, and what they hope to achieve in the future. To enable people who use the service to comment on the care it provides, we sent surveys to fifteen people living at the home, eight of which were returned, ten to staff, five were returned, and five to local doctors and health care workers (social workers, community nurses), two were returned at the time of writing this report. (Surveys were returned following the visit to the home.) The comments in the surveys were positive about the standard of care provided by the staff at the home. People living in the home are protected from abuse and they can be confident that their complaints will be listened to and acted upon. We would like to thank all people who gave feedback about the home, and would like to thank the manager and staff for their co-operation throughout the inspection process. Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 7 What the service does well: The intermediate care plans were comprehensive and of a good standard and the multidisciplinary team continued to be involved in writing the plans and contributing to the care delivered. People who were receiving intermediate care commented on how they had enjoyed her stay. Comments from health care professionals about what the service do well include; “Referrals are made quickly to the district nursing team if required.” And, “Alert us with any problems/ concerns. Helpful and friendly staff.” Comments from relatives include; “The carers are wonderful here, nothing is too much for them, they are always here when needed.” During this visit staff were observed to maintain the privacy and dignity of people. Staff approached and spoke to people in an appropriate manner. As a tribute to the standard of food provided the home has received a five star, Excellent award in association with Kirklees Councils Health Choice Award, Scores on the doors. What has improved since the last inspection? What they could do better: The organisation of the care plans needs to be clear to ensure that anyone reading them can understand them, and staff should ensure that the daily recording of the care given fully reflects the identified needs of the person. Activities need to be made available on a daily basis, and arrangements made for people to take part. Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 8 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 9 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 Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assessed prior to them moving into the home and are able to visit to establish whether or not it is the right place for them. People who are assessed and referred for intermediate care are helped to increase their independence and return home. EVIDENCE: The information received from the manager prior to inspection, states that before a person is admitted to the home for long term care, a senior member of staff visit them in their place of residence and carries out an assessment of their needs. A community care assessment is also obtained, and once staff are satisfied that the persons needs can be met then they are sent a letter offering them a place at the home. This was also confirmed by staff at the time of the inspection. Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 11 People who use the service said that they received enough information about the home before they moved in. When a person who is to be admitted requires intermediate care, the staff obtain a community care assessment and contact health care professionals to ensure that they have up to date information about the persons. Once the staff are confident that they can meet the persons needs, then that person is offered a place. Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples’ care plans outline the level of support and care each person requires in ensuring their health and welfare needs will be met. The recording and administration of medication is satisfactory. People are treated with respect. EVIDENCE: Three care plans of people who receive long term care were looked at, and new documentation had been introduced since the last inspection. The information was held in several files, some of the information seemed to be repeated and confusing as care plans had been written, and then a mini plan written to use with the daily record, which needed to be explained. The manager said that if someone came to work from outside of the home, then a detailed report would be given to them to ensure that they were aware of the care the person needed. Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 13 The care needs of the person had been identified and the daily record gave an account of the care given that day. Staff need to ensure that the daily recording of the care given fully reflects the outcome of the identified needs of the person. Their social, cultural, religious needs, and likes and dislikes were also recorded, and people confirmed that staff respect individuals privacy and dignity. One person said, The carers are wonderful here, nothing is too much for them. They are always here when needed.” Comments received from staff regarding care issues/ planning include, “Listen to care staff opinions in regard to client personal care etc. Work together more closely on care planning.” The intermediate care plans were comprehensive and a good standard and the multidisciplinary team continued to be involved in writing the plans and contributing to the care delivered. People who were receiving intermediate care commented on how they had enjoyed their stay, and one of those people also said that she had been well looked after. People said that they receive the care and support they need, and that staff listen and act on what they say. There was also evidence of involvement from peoples doctors, physiotherapists, opticians, dentists and other health care professionals where needed, and a comment from a health care professional includes, When asked if the service seek advice and act upon it to manage and improve individuals’ health care needs. One person recorded, “Always” and a second person said, “Most staff act on the advice however, communication to other staff occasionally a problem.” When also asked if individuals’ health care needs are met by the care service. One person recorded always and another person recorded usually. When asked, what the home does well, comments include, “Most clients appear clean, presentable and their needs attended to. Referrals are made quickly to the district nursing team if required.” “Alert us with any problems/ concerns. Helpful and friendly staff.” During this visit staff were observed to maintain the privacy and dignity of people. Staff approached and spoke to people in an appropriate manner. Following the last inspection there have been a number of notifications to the Commission about medication errors. Appropriate action was taken by the manager at the time and has now been resolved. The medication of three people was checked and all were found to tally with the records held. Records were clear and accurate, and medication was stored correctly. Systems are in place to ensure safe administration of medication. Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12 – 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home have choice over their lives and some social activities are provided. They are encouraged to maintain contact with their family and friends. People receive a varied diet and in pleasant surroundings. EVIDENCE: People’s social interests continue to be recorded in their care plan and included information about their past hobbies and interests. An activities coordinator is employed two to three days each week at Moorlands Grange, and is also shared with another Kirklees home. A programme of events was seen on the notice boards however it did not include what was available on a daily basis, as when the activities person was not working, nothing was recorded. The information that was provided prior to inspection states that people are involved in determining activities, in residents meetings, questionnaires and care plans. In the care records inspected, the Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 15 information had been recorded ad hoc. At the last inspection a recommendation was made about recording of activities that people take part in, and this was discussed with the manager. At the time of this visit the activities person was working in the home and people were enjoying playing dominos. There was a general buzz, and people commented on how much they enjoyed the game. The WRVS shop comes to the home each Tuesday. The information provided prior to inspection states that local schools are encouraged to visit, and there are links with the local community with regular church services. Out of the 8 surveys received from people who live at the home, 2 people said that there were always activities that they could take part in. 2 people said, usually, and 3 said that there are sometimes activities arranged by the home that they can take part in. One person said, “I don’t get involved with activities, I like to watch my television. A health care professional, when asked how she thought the service could improve, said, “More activities to entertain the clients and provide improved stimulation.” And a member of staff said, “The clients could do with more going on regarding activities. Something to keep them alert and not be fed up.” The League of Friends of Moorlands Grange continues to work in helping to enhance the quality of life for residents at the home. People said that they could see their visitors in private and that they were always made welcome. The menus offered a variety of food and took account of individual peoples’ food preferences; specialised diets and cultural needs. People who were spoken with on the day said that the food was lovely. One person said,”I really enjoy the meals, they are cooked meals which I enjoy.” Another person said, “The meals are first class, plenty of choice.” Without exception all people who completed the surveys said that they liked the meals. As a tribute to the standard of food provided the home has received a five star, Excellent award in association with Kirklees Councils Health Choice Award, Scores on the doors. Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that their complaints will be listened to and acted upon. Staff have received suitable training and understand the adult protection policies and procedures, which makes sure that the people they support are safe. EVIDENCE: The complaints procedure is located displayed on the notice boards in each dining room/ lounge, and also made available to people and relatives, within the Service User Guide. According to the information provided by the home, there have not been any complaints within the last twelve month. The surveys indicated that four out of seven people who use the service knew how to make a complaint, and one persons’ relative said, “Would make herself heard if not happy about things.” We would recommend that people are reminded of where the complaints procedure is located. Evidence showed that all staff have received safeguarding (adult protection) training which provides information on how to protect people from abuse. Staff who were spoken with said that they were aware of the procedure to follow if Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 17 they suspected abuse of a person, and that they were also aware of the homes Whistle blowing policy. Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is in a good state of repair and decorative condition and peoples’ individual needs are met in a comfortable and modern setting. The premises are clean and systems are in place to control the spread of infection. EVIDENCE: As part of the inspection a tour of the home took place, which included the communal areas, a number of bedrooms and the laundry. The building is spacious, and all bedrooms have en suite facilities. The home continues to be in a good state of repair and maintained to a high standard. New floor coverings have been fitted in the dinning rooms/ lounges. Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 19 The outdoor space is easily accessible, and has various seating areas, including a covered Pagoda, and the gardens are a pleasant area where people can go. The premises were clean and systems are in place to control the spread of infection. Six of the surveys received from people who use the service said that the home was always fresh and clean and two people said that the home is usually fresh and clean. One of the staff said in their survey, that to improve things at the home, someone in the laundry full time, who could be responsible for returning peoples clothing, would be beneficial to staff. Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27 – 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staffing levels and skill mix were sufficient to meet the number and needs of service users. Service users are supported and protected by the home’s recruitment practices. EVIDENCE: There was a sufficient number and skill mix of staff on duty to care for the number of people living in the home. Out of the surveys received from people who use the service six people said that there was always staff available when they need them and two said usually. One person made the comment, “…”nothing is too much trouble for them, they are always there when needed.” The information received prior to inspection states that, the staff group receive a high level of training opportunities and staff development is a high priority. 93 of care staff has an NVQ 2 or equivalent. Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 21 Care practice observed during this visit, and the relationship between staff and people being cared for was positive. Samples of recruitment records were inspected and the correct information and checks had been carried out. There was also evidence in the staff records and staff confirmed that they had induction training, oral health, fire, dementia awareness, infection control, and movement and handling training. Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from the management approach of the home and the manager ensures so far as reasonable practicable that the health, safety and welfare of people and staff are protected. The home is run in the best interest of people who live there. EVIDENCE: The manager has a number of year’s experience of working with older people and has completed the registered managers’ award and also a National Vocational Qualification level 4 in care. Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 23 Although the manager was there on the day of the visit, she has been seconded for a few weeks to help with other homes within the group. She confirmed that she proposed to return to the home in the near future. The deputy manager is in the short term, there on a day to day basis and is supported by the manager and other senior staff. For those people who wish small amounts of personal monies are held safely at the home. The financial records of four people were examined and were satisfactorily were maintained. Receipts are kept of all transactions made. Discussion took place with the manager regarding the need to have individual receipts for hairdressing. The group manager visits the home monthly and writes a written report on the conduct of the home. In addition to this, when the people who have received intermediate care are discharged home, they are asked if they would complete a survey about how the home can improve on the service. The surveys are then discussed at the staff meeting and improvements made as appropriate. Separate surveys are sent out to people who receive long term care, and the results, which were seen were positive. Three monthly relative meetings have commenced, and minutes were seen of the meeting held in March 2009. The manager said that she has an open door policy, making herself available for anyone who would wish to speak with her. At the last inspection a recommendation was made regarding staff having supervisions 6 times a year. The information received from the manager prior to inspection stated that staff have regular supervision. The sample of staff records showed that some improvement has been made, and the supervision of staff is becoming more regular. The surveys returned by staff confirmed that a number of staff had regular meetings with their manager or Care Coordinator who gave them support and discussed how they are working. The manager said that there are four staff responsible for fire training (facilitators.) Records showed that fire lectures and drills take place. The fire alarm has been tested weekly until the 8th April 2009. The week following this date, the test was not recorded. This was identified at the last inspection, and although this time seems to be an isolated occurrence, steps should be taken by the manager to ensure that weekly tests take place. Routine health and safety checks are carried out and appropriate records were seen. Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 25 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. OP12 Standard Regulation 16 Requirement Consult people about an activities programme and make arrangements for them to take part. Timescale for action 22/06/09 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 organisation of the care plans needs to be clear to ensure that anyone reading them can understand them. Staff should ensure that the daily recording of the care given fully reflects the outcome of the identified needs of the person. 2. OP7 The organisation of the care plans needs to be clear to ensure that anyone reading them can understand them. Staff should ensure that the daily recording of the care given fully reflects the outcome of the identified needs of the person. Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 26 3. 4. OP16 OP38 As not everyone knew how to make a complaint, staff should remind people where a copy of the complaints procedure is located. Fire alarms should be tested every 7 days and recorded. Moorlands Grange DS0000067432.V375163.R01.S.doc Version 5.2 Page 27 Care Quality Commission Yorkshire & Humberside Region PO Box 1254 Newcastle upon Tyne NE99 5AR National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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