Care Home: The Grange Care Home

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What the care home does well What has improved since the last inspection? Medication records are audited on a regular basis and improvements have been made in the recording of the administration. All staff have received adult protection training. The home has implemented schedules to control the risk of infection and some staff have received infection control training. All staff now have an individual training and development assessment and profile. Senior staff have been appointed and there are clear and delegated responsibilities outlined for each shift. What the care home could do better: Staff comment: `I would like to see more funding for training to improve knowledge and free uniforms.` `Funding to provide outings for service users, which could improve their quality of life`. The Registered Manager says that the funding refers to NVQ and there is an ongoing programme to achieve this award. Service user comments: `Outings have been discussed but never taken place. A change of scenery for short periods would be welcome`. `Sunday lunches are always palatable; otherwise the menus are boring, monotonous and flavourless.` (my one criticism of the establishment). `Quite honestly there are hardly any activities. We did have a meeting and someone asked for board games, the manger is trying to do more things`. Relative comment: The home could improve by providing more one to one activities`. The Registered Manager has held a meeting to discuss the issues about food and activities, including outings and is taking action to address these issues. Further details are in included in this report.The home needs to ensure that the kitchen floor is replaced when the kitchen is refurbished and comply with the recommendations made in the last environmental health visit. The home needs to consult with the Fire and Rescue Service/Environmental Health with regard to the use of window restrictors on the first floor. CARE HOMES FOR OLDER PEOPLE The Grange Care Home 22 Cornwallis Avenue Folkestone Kent CT19 5JB Lead Inspector Mrs Penny McMullan Unannounced Inspection 17th June 2008 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 Care Home DS0000041005.V365596.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 Care Home DS0000041005.V365596.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Grange Care Home Address 22 Cornwallis Avenue Folkestone Kent CT19 5JB 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) 01303 252394 F/P 01303 252394 thegrange@ashwoodhealthcare.co.uk Ashwood Court Healthcare Ltd Mrs Carol Weeks Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places The Grange Care Home DS0000041005.V365596.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th September 2007 Brief Description of the Service: The Grange is a large extended detached property situated in its own grounds, with well-maintained gardens at the front and back of the home. There are two lounge/dining rooms and a quiet room/conservatory on the ground floor. There is also a spacious porch with seating, where residents are able to relax. The property has two floors and the home has a shaft lift. There are 28 single bedrooms, 20 of which have en suite facilities. The home is situated in Folkestone, close to local shops and other public amenities including the local bus service. The statement of purpose gives information about the service. A copy can be obtained from the home. The most recent inspection report can be seen in the home. Currently the scale of fees is between £312 and £475. Hairdressing, chiropody, transport, papers, toiletries and holidays are at an additional charge. The Grange Care Home DS0000041005.V365596.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that the people who use the service experience good quality outcomes. This key inspection was carried out over a period of time and concluded with an unannounced visit to the home between 9.30am and 5.45pm. Residents and staff were spoken to. Observations included interactions between residents and staff. Surveys were sent to the home to distribute to residents, relatives and professionals. Feedback from the people who use the service and relatives is positive. No professional surveys were received back. Various records were viewed during the inspection and a partial tour of the home undertaken, including the communal areas, some bedrooms, bathrooms, and laundry facilities. The last AQAA was received in September last year and the home has updated the information and provided a copy to the Commission. What the service does well: Feedback from the people who use the service, relatives, and staff is positive. Comments taken from the postal surveys, residents and staff included: Service users’ comments: ‘I am very happy’. ‘Staff are extremely helpful and kind’. ‘I am very satisfied’. ‘The staff are very good at listening to what I say’. ‘Care is very good’. ‘I am very satisfied’. ‘Staff are lovely – they do their best – I have no complaints’. ‘I think I would be hard pushed to find anywhere as comfortable as this’. ‘The staff are good, there is nothing to improve on, they come at the touch of the bell’. ‘The Manager and Deputy are very helpful and the staff are very nice’. ‘I would recommend this home’. The following comments are taken from compliment letters sent to the home: ‘My relative has received excellent care, particularly when ill’. ‘We continue to be impressed with the Grange it is managed extremely efficiently and I can think of nothing to criticise in any way – brilliant’. The Grange Care Home DS0000041005.V365596.R01.S.doc Version 5.2 Page 6 Staff comments: ‘Respects privacy of service users, care is excellent and facilities for all needs required. The home is clean and has a friendly environment’. ‘I am very happy and satisfied with all aspects of my job’. ‘The service provides well trained and well mannered staff to give help and support to each and every individual within the home environment. Welllayered care plans are very descriptive, updated and reviewed regularly. This ensures each individuals dignity, self respect and privacy is encouraged and promoted on a daily basis’. ‘Good communication skills’. Relative/friend comment: ‘Overall this is a good home’. What has improved since the last inspection? What they could do better: Staff comment: ‘I would like to see more funding for training to improve knowledge and free uniforms.’ ‘Funding to provide outings for service users, which could improve their quality of life’. The Registered Manager says that the funding refers to NVQ and there is an ongoing programme to achieve this award. Service user comments: ‘Outings have been discussed but never taken place. A change of scenery for short periods would be welcome’. ‘Sunday lunches are always palatable; otherwise the menus are boring, monotonous and flavourless.’ (my one criticism of the establishment). ‘Quite honestly there are hardly any activities. We did have a meeting and someone asked for board games, the manger is trying to do more things’. Relative comment: The home could improve by providing more one to one activities’. The Registered Manager has held a meeting to discuss the issues about food and activities, including outings and is taking action to address these issues. Further details are in included in this report. The Grange Care Home DS0000041005.V365596.R01.S.doc Version 5.2 Page 7 The home needs to ensure that the kitchen floor is replaced when the kitchen is refurbished and comply with the recommendations made in the last environmental health visit. The home needs to consult with the Fire and Rescue Service/Environmental Health with regard to the use of window restrictors on the first floor. 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 Care Home DS0000041005.V365596.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Grange Care Home DS0000041005.V365596.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that residents have the information they need before making a decision to move into the home. Residents are assessed prior to admission to ensure that the home can meet their needs. EVIDENCE: The Statement of Purpose and Service User Guide have been updated and are available for prospective residents. These documents clearly outline the services and facilities available within the home. This helps people decide whether the home can meet their needs. Care needs assessments are carried out for all prospective residents. They are invited to visit the home to have an opportunity to view the premises and meet The Grange Care Home DS0000041005.V365596.R01.S.doc Version 5.2 Page 10 with staff and residents. Care plans from the placing authority or hospital are also on file. This information is important to assist the home to meet the identified needs of the person. Assessments were viewed and contained the relevant details. The Registered Manager also demonstrated her awareness of the importance of a detailed assessment to ensure physical and mental health needs can be meet. Standard 6 does not apply to this service. The Grange Care Home DS0000041005.V365596.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care, which a resident receives, is based on their individual needs. The principles of respect, dignity and privacy are put into practice. Arrangements are in place to ensure the safe administration of medication and health needs are well supported. EVIDENCE: The care plans give staff the details they need to meet the needs of the residents. There are individual to residents and when required additional information is added, for example, observational hourly checks. The plans record medical appointments, including GP, District Nurse and if required Community Psychiatric Nurse visits. The plans clearly monitor all health care needs including, weight, skin integrity and nutrition. There are risk assessments in place and evidence that the plans have been reviewed. The The Grange Care Home DS0000041005.V365596.R01.S.doc Version 5.2 Page 12 size of the moving and handling equipment needs to be consistently recorded to ensure that staff have clear guidelines of correct equipment to be used with individual residents. Residents are involved with the plans and sign their care plan. A health care professional comment: ‘The home promotes the health care of the residents and they do not hesitate to contact us if required’. The medication systems were examined. Medication Administration Records (MAR) charts are in good order with the use of signatures and codes. The Registered Manager, Deputy or senior member of staff, ensures that audits are carried out and staff are aware of the importance in reporting any gaps that may occur. It is recommended the home ensure that all written entries in the MAR sheets are countersigned to reduce the risk of error. A thermometer has been installed in the storage areas to ensure medication is stored at the correct temperature. Staff have received the administration of medication training. Residents confirm that staff always treat them with respect and ensure privacy and dignity is upheld. Good interactions between residents and staff were observed during the visit. A service user comments: ‘Yes staff respect my privacy and dignity and they are extremely good – very good, kind’. The Grange Care Home DS0000041005.V365596.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is in the process of reviewing activities to ensure that the resident’s interests and preferences are included in the programme of events. Visitors are welcomed in the home and arrangements are in place for the people who use the service to be supported to make choices in their lives. EVIDENCE: Some residents are able to go out for a walk and access the local community, which they do. Some residents rely on families to take them out. There is no formal programme of activities but residents say that bingo sessions will restart and one service user has agreed to call the numbers. The home is proactive in promoting activities and this subject was discussed at the recent residents meeting. Residents have made suggestions, which the home is in the process of actioning. It was discussed at the last inspection that more outings were requested, however when one was arranged although there was initially a good response when the date arrived it was cancelled as only two residents The Grange Care Home DS0000041005.V365596.R01.S.doc Version 5.2 Page 14 wished to participate. Interests are recorded in the care plans and residents say they do have some entertainment and sing songs. Residents spoken to expressed different views, some said they would like more activities whilst others said they preferred to do their own thing. The home needs to continue to discuss this with service users and focus on individual preferences to promote social stimulation. Residents requested a herb garden, which is now in place. The church visits the home on a monthly basis and there is a weekly church club held each Tuesday. Routines are flexible and residents confirm they are able to choose what they do. Residents were observed going out, sitting in the lounge and enjoying the garden. Relatives spoken to at the time of the inspection confirm that the home welcomes them and they are offered refreshments when they visit. One-visitor comments: ‘The home has been wonderful as my relative is very poorly we are visiting all the time and they are doing a really good job’. The dining room is pleasant and the atmosphere at lunch was very relaxed with plenty of conversation. There was a choice of drinks available with the meal. There are mixed comments from residents spoken to and postal surveys with regard to the meals, four say they always like the meals, three say sometimes and one usually. Two comments were: ‘They do their best’. ‘I like the meals most of the time’. Another resident said: ‘You can’t always like the meal every time’. At the time of the visit a resident said: ‘They always ask you what you want for lunch, you can pick from two choices and if you don’t want any they will offer you something else’. The lunch served at the time of the visit looked appetising, and alternatives were also being served. Residents commented that the meat was tender and it just ‘falls to bits’. Several residents commented how nice the cheesecake was. Two residents said they would like their plates to be warmed. Carers were observed sensitively supporting service users to eat. The home caters for individual dietary preferences and has joined the Vegetarian for Life UK list and agreed to abide by its Code of Good Practice. A resident with diabetes also says that they cater for her needs very well. The Registered Manager says that there have been several different cooks over the last year and the current cook is relatively new in post and a new weekend cook has now been appointed. With the new team in place she is confident the menus will improve. She acknowledges the issues and has discussed the meals with residents at the meeting held on 11th June 2008. The suggestions from the residents have been noted and the menus will be reviewed accordingly. Residents confirm that their views are being listened to. The Registered Manager has provided the residents with a suggestion form and these are currently being completed. This information will be used to influence the review of the menus. No requirement or recommendations will The Grange Care Home DS0000041005.V365596.R01.S.doc Version 5.2 Page 15 be made in this report as the home is committed to improving the meals and listening to the views of the residents. All of the necessary checks and kitchen records are in order and resident likes and dislikes are recorded in individual care plans. The Grange Care Home DS0000041005.V365596.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are confident complaints will be listened to and dealt with appropriately. Arrangements in place to ensure service users are protected from abuse. EVIDENCE: The complaints procedure is displayed in the home. Residents spoken to are well aware of how to complain and would not hesitate to speak to the Registered Manager. They are confident in complaining to the manager and feel she would deal with any concerns quickly. The home has a complaints log in place and there has been one formal complaint since the last inspection. The Registered Provider responded to this issue within the appropriate timescales. There are polices and procedures in place to ensure staff have guidelines to report safeguarding issues. All staff have received adult protection training and the home’s recruitment policy ensures that staff providing care have been appropriately vetted. The Grange Care Home DS0000041005.V365596.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from living in a homely environment, which is clean, comfortable and well maintained. EVIDENCE: The home is well maintained and decorated to a good standard, providing residents with a nice, comfortable and homely place to live. The grounds and garden are well kept with seating and parasols for residents to use. The previous environmental health office visit highlighted the need to renew kitchen units and worktops. At the time of the site visit this had not been started but the Registered Manager says that quotes for the kitchen and laundry refurbishment have been provided to the Registered Provider for action to be taken. In the previous inspection report it was stated that the home must replace the kitchen flooring. Since the last inspection this has been The Grange Care Home DS0000041005.V365596.R01.S.doc Version 5.2 Page 18 repaired and sealed, however this still remains unsuitable and will need to be added to the refurbishment plan for the kitchen. It is recommended that the home comply with all of the areas highlighted in the environmental health report. As there is action being taken with regard to this issue no requirement or recommendation will be made at this time. There is no formal programme in place for routine maintenance or renew of fabric, however it is evident that this is taking place on a regular basis. The home has a fire risk assessment in place. The Registered Manager says that it is in the process of being reviewed and this will be carried out sometime next week. No requirement or recommendation will therefore be made at this time. There is one toilet where a hand basin is not fitted; there is insufficient room to address this issue. Therefore the home has put a liquid hand gel in place. A risk assessment will also be implemented to ensure that residents and staff are aware of this arrangement to ensure that infection control procedures are adhered to. The laundry is being refurbished and commercial washing machines will be provided. The laundry room was clean and tidy with infection control procedures in place. The sluicing area now has hand-washing facilities in place. Feedback from residents and staff indicates the home always has a pleasant smell and is clean and tidy. The Grange Care Home DS0000041005.V365596.R01.S.doc Version 5.2 Page 19 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from qualified, trained staff that are caring and kind. The home’s recruitment procedures protect the residents. Arrangements are in place to ensure that residents are protected by the home’s recruitment procedures. EVIDENCE: At the time of the site visit there were sufficient staff on duty to meet the needs of the service users. The rotas show that additional staff are on duty at the busiest times and the Deputy Manager can be either rostered to provide direct care or allocated to office duties. There were also two domestics, one cook and a handyperson on duty. The home has introduced a staffing schedule for each shift, which identifies the senior staff on duty and indicates who is responsible for areas of the home and general tasks to be carried out. Residents, staff and relatives spoken to all feel there is enough staff on duty. Resident’s comments are very complimentary to the Manager and staff and examples of their comments have been included in this report. The Grange Care Home DS0000041005.V365596.R01.S.doc Version 5.2 Page 20 Staff files were sampled and contained the relevant documentation to show that staff are appropriately vetted. Files contain CRB (Criminal Record Bureau) and the Protection of Vulnerable Adult checks, together with proof of identification and two satisfactory written references. Staff interviews are recorded and signed by the manager and applicant. There are currently just over 50 of staff completing NVQ 2 or above or have completed the award. A staff member spoken to said she was looking forward to doing her level 3. There is an ongoing training programme in place with further courses to update mandatory training being booked. The Registered Manager and Deputy are also in the process of updating their training, for example first aid and moving and handling. Staff have also received dementia and challenging behaviour training. Mental Capacity training has been arranged for July. Every individual member of staff now has a training and development assessment. Staff confirmed they had completed induction training and ongoing training is being provided. Comments from the postal surveys are as follows: ‘My manager went through everything with me, and was very competent and thorough’. ‘My induction was very good and covered all aspects of my job description’. The Grange Care Home DS0000041005.V365596.R01.S.doc Version 5.2 Page 21 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): 31,33,35,36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a well managed home which is run in their best interests. Arrangements are in place to ensure the people who use the service financial interests are protected. Residents and staff are protected by the arrangements in place to minimise risk and promote health and safety. EVIDENCE: Residents spoke very highly of the manager and had confidence in her ability to run the home efficiently. She is qualified and experienced. Staff confirmed The Grange Care Home DS0000041005.V365596.R01.S.doc Version 5.2 Page 22 that she was very supportive when they first started work and continues to provide support. A health care professional commented: ‘The Registered Manager is excellent and the Deputy Manager is also good, they are able to handle complex care situations very well’. Staff comment: ‘My manager has been very supportive from my first day, she explains everything very well, is friendly and easy to approach. Our new assistant manager is supportive and friendly and is always there if assistance is needed.’ The space allocated to the Registered Manager for her office does not always ensure that confidential information can be discussed in a secure environment. The Registered Manager is aware of this situation and says that confidential discussions usually take place in the enclosed small entrance to the home. A quality assurance questionnaire was sent out in May and the results are forwarded direct to their head office to be summarised and actioned. At the time of the site visit the results had not been received, however it is evident that a consultation process is in place. Staff also received a questionnaire to complete to ensure that everyone involved in the home had the opportunity to feedback on the services provided. The Registered Provider visits the home on a regular basis and completes a report on the service. There are plans to refurbish the kitchen and laundry, which are currently being discussed, but there is no formal development plan in place. The Registered Manager is going to discuss the implementation of a formal written development plan with the Registered Provider. Some residents are supported with their financial needs. There are systems in place to ensure that all monies are recorded, receipts given and in some cases residents are able to sign for money received. The Registered Provider makes unannounced monthly visits to the home to audit these records. There is a supervision programme in place and staff confirm supervision is in place and staff providing this supervision have been trained to do so. There are health and safety polices and procedures in place, together with environmental risk assessments. There is a programme to ensure that mandatory training and updates are provided. The Registered Managers says that the fire risk assessment is being reviewed during the next week. The home needs to consult with the Fire and Rescue Service and Environmental Health to assess the use of window restrictors on the first floor windows in the home. The fire book is in good order with recorded fire drills and maintenance/servicing of equipment calls. Accident and incidents are recorded appropriately and a sample to confirm safety checks are taking place was made. The Grange Care Home DS0000041005.V365596.R01.S.doc Version 5.2 Page 23 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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 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 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 The Grange Care Home DS0000041005.V365596.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP9 OP19 Good Practice Recommendations To ensure that all handwritten entries are countersigned on the MAR sheets to minimise error To consult with the local Fire and Rescue/Environmental Health Office with regard to the use of window restrictors on the first floor of the extension and to comply with the previous Environmental Health Report recommendations The Grange Care Home DS0000041005.V365596.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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