Inspection on 13/10/06 for Gravesham Place Integrated Care Centre

This inspection was carried out on 13th October 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Gravesham Place Integrated Care... 14/01/09

Gravesham Place Integrated Care... 17/03/08

Gravesham Place Integrated Care... 17/08/07

Gravesham Place Integrated Care... 07/03/07

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Gravesham Place Integrated Care Centre 22-22a Gravesham Place Stuart Road Gravesend Kent DA11 0BZ Lead Inspector Helen Martin Key Unannounced Inspection 13th October 2006 11:30 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 Gravesham Place Integrated Care Centre DS0000067174.V301307.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. Gravesham Place Integrated Care Centre DS0000067174.V301307.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gravesham Place Integrated Care Centre Address 22-22a Gravesham Place Stuart Road Gravesend Kent DA11 0BZ 01474 360500 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) Kent County Council Susan Barbara Giblin Care Home 80 Category(ies) of Dementia - over 65 years of age (40), Old age, registration, with number not falling within any other category (40) of places Gravesham Place Integrated Care Centre DS0000067174.V301307.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 7 of the 40 elderly dementia beds may be used for service users aged 55 years and over for dementia. 3 of the 20 older people beds may be used for service users aged 55 years and over for rehabilitative care. 20 of the 40 older people beds are provided for people requiring nursing care. N/A Date of last inspection Brief Description of the Service: Gravesham Place Integrated Care Centre provides accommodation for eighty older people. Forty places are for older people, twenty of which can be for nursing care and three for rehabilitation from the age of fifty-five. Forty places are for older people with dementia, seven of which can be from fifty-five years of age. The home is divided into three units, Topaz, Opal and Emerald. Grosvenor Facilities owns the building and the care service is provided by Kent County Council. The home is part of a complex that includes a hospital and day services, which is located in Gravesend within easy reach of the usual town facilities and public transport. Each unit of the home has access to outside areas, such as gardens, a balcony and a roof garden. The car park to the front of the property is currently not available for visitors to the home, although additional facilities are planned. All residents are accommodated in single rooms with ensuite facilities. The home is purpose built and can be accessed at all levels by the use of a passenger lift. The centre provides a management structure and provides nursing and care staff, working a roster, which gives 24-hour cover. Staff are also provided for residents’ activities, catering, housekeeping and domestic duties. Information regarding current fees for the home was not included within the home’s pre-inspection questionnaire or available at the time of inspection. Additional costs include hairdressing, toiletries, chiropody, some outings and newspapers. Information about the fees payable, the service provided and the home’s Statement of Purpose are available from the manager. Gravesham Place Integrated Care Centre DS0000067174.V301307.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place on 13th and 17th October 2006. The first visit included talking with the senior team leader, one nurse, one carer and four people who live in the home. The second visit included speaking with the manager. A telephone conversation was also held with the manager on 16th October 2006. Some judgements about the quality of life within the home were taken from observation and conversation. Some records were looked at. A tour of the home and garden was undertaken. The home has given the CSCI a completed pre-inspection questionnaire and this information has been used within this inspection where appropriate. What the service does well: What has improved since the last inspection? What they could do better: Prospective residents and their representatives do not have all of the information they need in order to decide whether to move into the home. Their health, personal and social care needs are not fully reflected in care plans. Residents are not fully protected by the procedures in place for the Gravesham Place Integrated Care Centre DS0000067174.V301307.R01.S.doc Version 5.2 Page 6 administration of medication. Residents’ choice regarding their bedroom doors could be improved. They would benefit from an updated written complaints procedure. A review of infection control procedures would confirm their protection. The potential risk to residents in the dementia unit must be reduced by improvements to the environment. It is of concern that despite assurances when registering this service that these matters would be addressed the risks to the premises still remain. Improvements to the recruitment procedure and record keeping would better protect residents. 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. Gravesham Place Integrated Care Centre DS0000067174.V301307.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 Gravesham Place Integrated Care Centre DS0000067174.V301307.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): 1, 3, 4, 5, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including visits to this service. Prospective residents and their representatives do not have all of the information they need in order to decide whether to move into the home. They are assessed to ensure that the home can meet their needs. EVIDENCE: The home has developed a statement of purpose dated May 2006. The information supplied regarding the categories of care provided and the age range of residents is conflicting and confusing. There is no detail about the consultation of residents regarding the operation of the home. The home has not yet developed a service users’ guide. Prospective residents are assessed before they move in, in order to ensure that the home is suitable to meet their needs. It was stated that there are currently no self-funding residents and the local authority has undertaken all Gravesham Place Integrated Care Centre DS0000067174.V301307.R01.S.doc Version 5.2 Page 9 assessments prior to admission. Prospective residents have the opportunity to look around the home before they move in. The home provides a service for older people, aimed at meeting a wide range of needs. This includes some nursing care and some provision for people with dementia. Part of the service that the home provides is for short-term care, some of which is respite care and some of which is rehabilitation. People provided with rehabilitation are accommodated on Topaz unit on the ground floor. Specialist facilities, equipment and staff are provided, such as a physiotherapist and occupational therapist in order that people can return to their own homes. Designated therapy rooms are provided within the centre complex. Gravesham Place Integrated Care Centre DS0000067174.V301307.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 poor. This judgement has been made using available evidence including visits to this service. Residents are treated with respect and their privacy is upheld. Their health, personal and social care needs are not fully reflected in care plans, Their health and safety is not assured by the premises. Residents are not fully protected by the procedures in place for the administration of medication. EVIDENCE: Care plans seen did not fully reflect the changing health and social care needs of residents. Documentation was not detailed and some information was not recorded. Health care records to monitor residents’ weight, diet and manual handling are not all complete. Care plans for people with dementia are not comprehensive and do not identify all the risks of living in the home or the associated staff guidelines. There are potential risks to the health safety and welfare of those service users living in the dementia care unit due to unsafe access to other units and exits from the premises. Reviews of care plans consist of dates with no written detail. The senior team leader explained that they were in the process of transferring more detailed information from the Gravesham Place Integrated Care Centre DS0000067174.V301307.R01.S.doc Version 5.2 Page 11 care plans of homes that residents had been accommodated in previously. Staff guidelines regarding for individuals’ wishes regarding death and dying are not recorded in all care plans. The manager stated that they planned to set up care plan workshops for staff. Residents have access to health and social care professionals. It was stated that district nurses, GPs and community psychiatric nurses visit the home on a regular basis. The home has access to psychiatric specialists and some services of the adjoining hospital if necessary. Arrangements are in place for the administration of medication. Storage is appropriate. Currently the home does not use any controlled drugs. Records for the administration of medication were completed appropriately, with the exception of handwritten entries seen, which were not countersigned as accurate by a second member of staff. Records are kept with photographs of residents and a signature list of trained staff. Although providing nursing care, the home does not use a registered agency for the disposal of waste medication. Residents’ privacy is respected. They are able to meet with any visitors in private, either in their rooms or in the smaller lounge areas. Each room has a telephone, which can be programmed to make outgoing calls. The senior team leader said that initial problems with the laundry had improved. Gravesham Place Integrated Care Centre DS0000067174.V301307.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 adequate. This judgement has been made using available evidence including visits to this service. Residents benefit from a range of activities and are able to keep in contact with their family and friends. They receive a varied diet. Residents’ do not have a choice regarding keeping their bedroom doors open, access to outside space is restricted due to safety reasons. EVIDENCE: Residents are able to make some choices within the constraints of group living and their own abilities. Currently residents’ room doors are kept shut due to fire procedures. The senior team leader said that the home has requested fire door closures to enable residents to have the choice of whether their room door is left open or not. It is of concern that service users cannot freely access outside space on the balcony without staff support as this area is unsafe. Residents have a choice of activities within the home. The senior team leader explained that two activities co-ordinators are employed, who provide art and craft, sewing, knitting and handicrafts. Staff also undertake activities with residents, such as softball and memory games. One resident runs a popular Gravesham Place Integrated Care Centre DS0000067174.V301307.R01.S.doc Version 5.2 Page 13 bingo session. Some residents are supported to go shopping and others attend day services within the centre complex, which provide a variety of activities. It was stated that activities are provided most days. The home provides accommodation to residents of differing ethnicity and staff are able to support individuals to attend specialist centres within the local community. Residents are supported to undertake religious observance of their choice if they wish. A chaplain visits the home and services are held twice a week. The grounds include a multi-faith chapel, which provides the facility for various forms of worship. Residents are encouraged to keep contact with their relatives and friends if they wish. Visitors are welcome in the home at any reasonable hour and are able to be received in private. The service and staff provided for catering is shared with the adjoining hospital. Residents are asked for their choice of food and this is recorded. There are three options, two main courses and one salad. The senior team leader said that specialist diets are provided, such as vegetarian, gluten free and kosher. It was mentioned that catering staff were flexible and that they would aim to meet the cultural dietary needs of individuals. Gravesham Place Integrated Care Centre DS0000067174.V301307.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. This judgement has been made using available evidence including visits to this service. The views of residents and their representatives are listened to and receive appropriate consideration, although they would benefit from an updated written complaints procedure. They are protected from potential abuse. EVIDENCE: Residents are at ease talking with staff who listen to their views and concerns. Regular residents’ meetings are held to discuss these. The senior team leader stated that all complaints were recorded. Kent County Council provides the home’s written complaints procedure. Documentation is dated 2003 and contains out of date information regarding the CSCI and no timescales for action after a complaint is received. Procedures are in place to protect residents from potential abuse. Gravesham Place Integrated Care Centre DS0000067174.V301307.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. This judgement has been made using available evidence including visits to this service. Residents benefit from living in a clean, tidy and well-maintained environment, although a review of infection control procedures would confirm their protection. The potential risk to residents in the dementia unit must be reduced by improvements to the environment. EVIDENCE: The premises are purpose built. Grosvenor Facilities owns the building and the care service is provided by Kent County Council. The home is part of a complex that includes a hospital and day services. The home is divided into three units, Topaz, Opal and Emerald. CCTV is provided in the main entrance of the home for the security of residents. Gravesham Place Integrated Care Centre DS0000067174.V301307.R01.S.doc Version 5.2 Page 16 Residents accommodated on each unit of the home have access to outside areas, such as gardens, a balcony and a roof terrace. The home has assessed residents within the dementia unit as unsafe to use the balcony without direct staff supervision as the surrounding railing and panel is approximately 3’ 6” high. The senior team leader recognises the potential risk to residents and stated that a higher surround has been requested from the owning company. It was mentioned that the higher surround of the roof terrace is safe for their use. There is flat access to outside areas for less mobile individuals. The garden is well designed and includes a multi-faith chapel and a covered walkway. The car park to the front of the property is currently not available for visitors to the home, although additional facilities are planned. It was stated that staff are supervising residents on the dementia unit closely as doors to the unit are not secure. It was observed at the time of this visit that there is easy access for residents with dementia to the adjoining unit for older people, the lifts and the stairs leading to the external door to the home, which is operated by a push button. The manager recognises the potential risk to residents and has ordered swipe card locks for the unit doors. The owning company has not yet provided these. This is of concern given the assurance at the point of registration that the units would be secure. There are doors linking the home with the adjoining hospital. These are secured and can only be accessed by authorised individuals. The company that owns the building provides maintenance staff and undertakes repairs. Recreational and communal areas are provided for residents on each unit, such as a lounge, dining area, quiet room and kitchenette. Rooms seen accommodating permanent residents were personalised and homely. All residents benefit from single rooms with ensuite toilet and shower facilities. In addition two bathrooms are provided for each unit, although only one can be used, as there is only one bath hoist. The senior team leader stated that currently this is not a problem. Residents are protected by low surface temperature radiators. Residents can access all areas of the home; there is a passenger lift. They have the specialist equipment and facilities that they need, such as grab rails and adjustable beds. Storage space is available for equipment. A staff call system is available. Different areas of the unit for people with dementia are decorated in different shades of colour. The senior team leader stated that, for those residents that are disorientated, memory aids are fixed to their doors. It was indicated that no further signage is presently needed. All the areas of the home seen were clean and tidy. A sluice room is provided for each unit of the home; all doors were locked with the exception of the sluice within the unit providing dementia care. Personal soap and towels are Gravesham Place Integrated Care Centre DS0000067174.V301307.R01.S.doc Version 5.2 Page 17 provided for residents within their en-suite facilities, although no provision is made for staff. The senior team leader said that they would review the system in place to ensure that infection control is maintained. Gravesham Place Integrated Care Centre DS0000067174.V301307.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including visits to this service. Staff are available in sufficient numbers meets residents’ needs. Improvements to the staff recruitment procedure would better protect them. EVIDENCE: The senior team leader confirmed that there are sufficient staff on duty to meet residents’ care and nursing needs at all times. It was mentioned however, that the home is in the process of recruitment as it is currently short staffed. The senior team leader explained that agency workers currently fill the short fall. It was mentioned that carers and administrative staff are directly employed by the home but that nurses and all other staff are contracted. The service and staff provided for laundry, cleaning and catering is shared with the hospital. The company that owns the building provides maintenance staff. Some staff are able to speak with residents in their first language. The recruitment procedure in place within the home aims to ensure that suitable staff are appointed to meet the needs of residents. Files seen for newer members of staff evidenced the necessary pre-employment checks such as, the Protection of Vulnerable Adults and Criminal Records Bureau check, although they did not evidence that a full employment history had been checked. Gravesham Place Integrated Care Centre DS0000067174.V301307.R01.S.doc Version 5.2 Page 19 The home’s pre-inspection questionnaire stated that thirty-four staff, which is 52 of the care staff team have achieved an NVQ level 2 or above. Documentation seen evidenced recent staff training, which included adult protection, medication, diabetes and dementia awareness. In addition the home’s pre-inspection questionnaire stated that staff training had included moving and handling, health and safety, infection control and first aid. Gravesham Place Integrated Care Centre DS0000067174.V301307.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including visits to this service. The manager endeavours to run the home in the best interests of residents, however they would be better protected by improvements to record keeping and health and safety issues. EVIDENCE: The home’s statement of purpose states that the registered manager has ten years previous experience in residential and day care for older people and an additional ten years experience in social and health care settings; they have a certificate in management and are awaiting verification for the registered manager’s award. Gravesham Place Integrated Care Centre DS0000067174.V301307.R01.S.doc Version 5.2 Page 21 A staff supervision structure is in place. One-to-one sessions are provided and recorded. As the manager is not a registered nurse, the nurses are provided with supervision from the senior nurse. They in turn are supervised by the manager and receive clinical supervision from outside of the home. Care staff are provided with supervision by either a team leader or a nurse dependant on which unit they work in. Residents’ meetings on each unit and staff meetings within the home are held on a regular basis. The quality assurance system for the home was discussed. Questionnaires following short-term care are sent out on a regular basis. The manager explained that the organisation will undertake an annual review that includes feedback from residents, their representatives and health and social cares professionals. The home has a system in place designed to protect the financial interests of residents. It was mentioned that small amounts of cash are held on behalf of some residents, although the majority either deal with their own affairs or have an external appointee. All rooms have a lockable facility. Inventories of residents’ personal possessions and valuables are not complete. Records of accidents and incidents are recorded appropriately. Other records looked at as part of this site visit have been mentioned previously within this report where appropriate. The company that owns the building provides maintenance staff who take responsibility for the regular testing and maintenance of equipment and facilities within the home. It was said that they maintain the necessary records. No information regarding maintenance records was included within the home’s pre-inspection questionnaire and none were available at the time of the visit. Other issues regarding the health and safety of residents have been mentioned previously within this report. Gravesham Place Integrated Care Centre DS0000067174.V301307.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 X 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 1 2 3 3 3 3 2 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 3 2 1 Gravesham Place Integrated Care Centre DS0000067174.V301307.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4(c) Requirement The registered person shall compile…a written…statement of purpose…which shall consist of a statement as to the matters listed in schedule 1. In that, the statement of purpose must provide clear and non-conflicting information regarding the categories of care provided and the age range of residents; documentation must include detail regarding the consultation of residents as to the operation of the home. 2 OP1 5 The registered person shall 22/11/06 produce a…service users’ guide which shall include the information listed in regulation 5. In that, the home must develop a service users’ guide for residents. 3 OP7 OP8 OP11 Gravesham Place Integrated Care Centre Timescale for action 22/11/06 15 …the registered person shall, after consultation with the service user, or a representative of theirs, prepare a…service user’s plan as to how…their DS0000067174.V301307.R01.S.doc 22/11/06 Version 5.2 Page 24 OP37 needs in respect of their health and welfare are to be met. In that, care plans must fully reflect all of the changing health and social care issues of residents and be completed in sufficient detail in order to evidence that their needs are being met. 4 OP9 13(2) The registered person shall make 22/11/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. In that, handwritten medication administration records must be countersigned by a second member of staff as accurate; as the home provides nursing care, they must use a registered agency for the disposal of waste medication. 5 OP16 22 The registered person shall establish a…complaints procedure for considering complaints made…by a service user or person acting on their…behalf. In that, the complaint procedure for the home must be updated to include accurate contact details for the CSCI and timescales for action after a complaint is received. 22/11/06 6 OP19 OP38 13(4) The registered person shall ensure that all parts of the home to which service users have access are…free from hazards to their safety; any activities in which they…participate are…free from avoidable risks and DS0000067174.V301307.R01.S.doc 22/11/06 Gravesham Place Integrated Care Centre Version 5.2 Page 25 unnecessary risks to their…health or…safety…are identified and so far as possible eliminated. In that, a review must take place regarding the upstairs balcony to ensure that the surrounding rail and panel is of sufficient height to protect residents with dementia. The risk of residents with dementia wandering into an adjoining unit of the home and having access to the stairs, lift and external door must be reduced. 7 OP26 13(3) The registered person shall make 22/11/06 suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. In that, residents with dementia must not have access to the sluice room. A review must take place regarding the method for maintaining infection control when staff are assisting residents within their en-suite facilities. 8 OP29 OP37 19 The registered person shall not employ a person to work in the care home unless…they have…obtained…the information and documents specified in…Schedule 2. In that, a full employment history must be obtained, together with a satisfactory written explanation of any gaps in employment. Gravesham Place Integrated Care Centre DS0000067174.V301307.R01.S.doc Version 5.2 Page 26 22/11/06 9 OP37 OP38 17(3)(b) The registered person shall 22/11/06 ensure that…records…are at all times available for inspection in the care home by any person authorised by the Commission to enter and inspect the care home. In that, records must be made available for inspection, in order to evidence the regular testing and maintenance of equipment and facilities within the home. 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 OP14 Good Practice Recommendations It is recommended that residents have a choice as to whether their bedroom doors a left open or not, whilst at the same time complying with fire regulations. It is strongly recommended that inventories of residents’ personal possessions and valuables should be completed appropriately. 2 OP35 OP37 Gravesham Place Integrated Care Centre DS0000067174.V301307.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Gravesham Place Integrated Care Centre DS0000067174.V301307.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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