Inspection on 17/08/07 for Gravesham Place Integrated Care Centre

This inspection was carried out on 17th August 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

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

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

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

Gravesham Place Integrated Care... 13/10/06

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 Lisbeth Scoones Key Unannounced Inspection 10:15 17 and 20th August 2007 th 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.V345221.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.V345221.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.V345221.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. 7th March 2007 Date of last inspection Brief Description of the Service: Gravesham Place Integrated Care Centre provides Health and Social Care in Partnership for eighty older people. Forty places are for older people, twenty of which can be for nursing care. Twenty places are for rehabilitative care, 3 of which may be used for residents aged fifty-five and over. Twenty 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. There is a visitors’ car park to the front of the property. All residents are accommodated in single rooms with en-suite facilities. The home is purpose built and can be accessed at all levels by the use of a passenger lift. The inspection report, Statement of Purpose and information regarding weekly fees charged is on display in the entrance hall. This information is also available from the manager. Additional costs include hairdressing, toiletries, chiropody, some outings and newspapers. Gravesham Place Integrated Care Centre DS0000067174.V345221.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 over two days on 17 and 20 August 2007 and comprised discussions with the manager, nurse in charge, occupational health therapist, the chef, team leaders and other staff. The nursing, dementia and intermediate care units were visited. A number of residents, visiting relatives and care staff were spoken with. Samples of the care plans, complaint records and other documentation were examined. Comment cards were left for residents and relatives to complete. 10 relatives and 14 residents card were returned. A care manager was contacted by telephone following the visit. Comments made are referred to in the report. The inspection process was further informed by an AQAA (Annual Quality and Audit) completed by the manager before the visit. Since the previous visit, an incident was investigated under adult protection procedures. The investigation is now concluded. What the service does well: What has improved since the last inspection? Following the previous inspection visit, the manager submitted a time scaled improvement plan in response to outstanding requirements. The majority of those requirements within her remit have been acted upon. As a result, some risks to residents have been reduced. Gravesham Place Integrated Care Centre DS0000067174.V345221.R01.S.doc Version 5.2 Page 6 The Service User Guide has been further updated and made available to all residents. There is evidence that care plans are written with the input and agreement of the resident and/or their relative. A system for the safe disposal of unwanted medication now incorporates appropriate record keeping. The complaints procedure has been reviewed What they could do better: Whilst care-planning training workshops have been provided, those care plans seen did not provide staff with comprehensive information. Those in the nursing units lacked a uniform format and approach as well as pertinent detail as discussed with the nurse in charge. Those in the dementia care unit had a uniform format and contained comprehensive information. An activities folder has been introduced. However, there were several gaps and information recorded did not include whether the resident had enjoyed the activity offered. Some of the care plans in the intermediate care unit need further detail. If previous care plans are used when a resident is re-admitted, the care plan should be reviewed. The previous inspections identified that some residents do not have a choice whether they wish to have their bedroom doors open. This situation applies to 8 of the 80 registered beds and has not been addressed. Residents in the dementia care unit would benefit from more person-centred activities such as reminiscence therapy. At the previous visit, the manager said that sensory equipment (snoezelen) had been ordered. No date is available for this provision. There has been a delay in providing meals that meet residents’ cultural needs. The chef said that these are now imminently available. The previous two improvement plans stated that the balcony height in the dementia care unit would be reviewed in view of the potential safety risks. Despite assurances given at the time of registration, the CSCI has not been informed whether a review has taken place and what action has been taken. Residents still do not have freedom of independent access to this space due to the risks involved. Gravesham Place Integrated Care Centre DS0000067174.V345221.R01.S.doc Version 5.2 Page 7 Whilst residents in the dementia care unit have access to a roof garden, this area does not provide the residents with adequate sensory stimulation. The previous two improvement plans required that residents be protected from the risk of infection by ensuring that staff are provided with appropriate hand wash facilities. No action has been taken in this respect. No action has been taken to make the environment look more homely with pictures, features and colour. This issue was first reported on at the time of registration and referred to in subsequent inspection reports. Serious concern was expressed about the lack of progress made and no communication received regarding some of the outstanding requirements. 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. Gravesham Place Integrated Care Centre DS0000067174.V345221.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 Gravesham Place Integrated Care Centre DS0000067174.V345221.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, 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives are provided with adequate information to decide whether to move into the centre. They are assessed to ensure that the centre can meet their needs. Residents assessed and referred for intermediate care are helped to maximise their independence and return home. EVIDENCE: The centre keeps its statement of purpose and service user guide updated. The recent update includes the arrangements for ascertaining residents’ views. It also includes information re additional charges made for toiletries, chiropody, newspapers and some outings. Suggestions for further review and additions such as the centre’s policy on smoking were made. Gravesham Place Integrated Care Centre DS0000067174.V345221.R01.S.doc Version 5.2 Page 10 Prospective residents are assessed before they move in, to ensure that the centre is suitable to meet their needs. It was stated that there are currently no self-funding residents and the local authority has undertaken all assessments prior to admission. Prospective residents have the opportunity to look around the centre before they move in. The centre provides a service for older people, aimed at meeting a wide range of needs. This includes 20 nursing care and 20 dementia care beds. The centre provides short-term respite and rehabilitation care. Specialist facilities, equipment and staff are provided, such as an occupational health team and physiotherapist in order that people can return to their own homes. Designated therapy rooms are provided within the centre complex. A resident said how grateful she was for regaining her confidence in preparation for going home. Gravesham Place Integrated Care Centre DS0000067174.V345221.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, 10,11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although improved, residents’ health, personal and social care needs are not fully reflected in their care plans. Residents’ health care needs are met. Residents are protected by the centre’s medication policies and procedures. Residents are treated with respect and their privacy is upheld. EVIDENCE: A sample of care plans seen did not fully reflect the changing health and social care needs of residents. In the nursing unit, the format was muddled and information difficult to find. (It is acknowledged that “care plan review” is on Gravesham Place Integrated Care Centre DS0000067174.V345221.R01.S.doc Version 5.2 Page 12 the agenda for the staff meeting on the 22nd August 2007). Continence management was inadequately recorded. In the dementia care unit more information is now recorded about residents’ likes and dislikes. As recommended at the previous inspection, staff would benefit from having access to residents’ Life History. Whilst activities folders are now maintained in the dementia care unit, many gaps were observed. It is evident that residents have access to health and social care professionals. It was stated that district nurses, GPs, community psychiatric nurses and older people specialist nurses visit the centre on a regular basis. The centre has access to psychiatric specialists and some services of the adjoining hospital if necessary. Medication charts were well maintained and good systems are in place to ensure appropriate disposal of waste medication. A BNF was dated 2003 and a current copy should be obtained. A visiting relative said that staff are cheerful, courteous and helpful. All residents spoken with said that the staff were kind and caring. 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 may be programmed to make outgoing calls. See also standard 19. In respect of palliative care, a care plan had not been updated reflecting the changing needs. Gravesham Place Integrated Care Centre DS0000067174.V345221.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, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from a range of activities but those provided in the dementia care unit should be enhanced. Not all residents can exercise choice and control over the lives. Residents are able to keep in contact with their family and friends. Residents are provided with a wholesome and varied diet but staff must be proactive in ensuring that residents’ cultural dietary needs are met. EVIDENCE: Residents have a choice of activities within the centre. Two activities coordinators are employed, who provide art and craft, sewing, knitting and handicrafts. A garden party has recently been held. Staff also undertake activities with residents, such as softball and memory games. Several residents said they would like more outings. Gravesham Place Integrated Care Centre DS0000067174.V345221.R01.S.doc Version 5.2 Page 14 At the previous inspection, the manager said that sensory features and equipment for the dementia care unit had been ordered. At this inspection it was noted that this had not been acted upon. The provision of person-centred activities, such as reminiscence therapy, must be included in the activities programme. Some residents are supported to go shopping and others attend day services within the centre complex, which provide a variety of activities. The centre provides accommodation to residents of differing ethnicity. See also standards 15 and 27. Residents are able to make some choices within the constraints of group living and their own abilities. At the previous inspection it was reported that those residents whose rooms are situated in link corridors can’t have their bedroom doors open due to fire regulations. This situation remains unresolved. See also standard 19. Whilst residents in the dementia care unit have access to an enclosed roof garden, there are few features of interest or simulation. Whilst residents have access to a balcony, they cannot freely access it without staff support, as this area is unsafe. This has been an issue since registration of the centre and it is of concern that the situation remains unresolved. 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. A resident said she enjoyed such visits. 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 at the centre at any reasonable hour and are able to be received in private. Two visiting relatives said, “ We visit regularly and know the staff well. “ The catering service and staff is shared with the adjoining hospital. It was noted that crisp tablecloths and serviettes are provided. Residents said they enjoyed the variety of the meals. However a comment was made that meals are sometimes a bit dry. Residents are asked for their choice of food and this is recorded. There are three options, two main courses and one salad. In respect of meals for residents with cultural dietary needs, the chef said that these are now provided. Gravesham Place Integrated Care Centre DS0000067174.V345221.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The views of residents and their representatives are listened to, complaints recorded and acted upon. Residents are protected from abuse. EVIDENCE: Since the previous inspection, the complaints process has been reviewed and now includes the action taken following investigation. Residents are at ease talking with staff who listen to their concerns. Regular residents’ meetings are held to welcome views and concerns. Procedures and staff training ensure that residents are protected from potential abuse. Gravesham Place Integrated Care Centre DS0000067174.V345221.R01.S.doc Version 5.2 Page 16 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, 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a clean, tidy and well-maintained environment which could be made more homely. A safety issue however remains outstanding. Residents are at risk due to poor infection control practices. 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.V345221.R01.S.doc Version 5.2 Page 17 As discussed at the time of registration and at subsequent inspection visits, the centre would benefit from some ”homely features” as particularly in corridors the home has a clinical appearance. It is of concern that this issue has still not been resolved. All residents have access to outside areas, such as gardens, balconies and a roof terrace. At previous inspection visits, concern was expressed, particularly on the dementia care unit that the balcony railing is too low and presents a safety risk. It was noted that trellises have been placed on top of the surrounding railings. However, these still do not guarantee compete safety. Two previous improvement plans state that that the arrangement would be reviewed. The manager confirmed in writing on 22 November 2006 that canopies, to maintain residents’ privacy from windows overlooking the balconies, have been ordered. Such canopies have not been installed. At this inspection, staff advised that residents rarely use the balcony and that the door accessing it is kept locked. An urgent response is now required as to the centre’s view on this and the action it plans to take. The garden is well designed and has disabled access. It includes a multi-faith chapel and a covered walkway. Swipe card locks have been provided in the dementia care unit thus ensuring safety for the residents. There are doors linking the home with the adjoining hospital. These are secured and can only be accessed by authorised individuals. Grosvenor Facilities is responsible for maintenance and repairs. As referred to in standard 14, those residents whose rooms are situated in link corridors cannot have their bedroom doors open due to fire procedures. In order to resolve this situation, it is recommended that the home contact the Fire Officer and inform the CSCI of the outcome. A resident commented on the high standard of cleanliness within the centre. All areas of the home seen were clean and tidy. However, as mentioned in the previous inspection report, staff must ensure that sluice rooms are clutter free to allow for effective cleaning. Residents are provided with en-suite facilities. The previous inspection report stated: “No hand wash facilities are provided for staff. Such facilities must be provided in respect of wall-mounted liquid soap and paper towel dispensers and a foot-operated bin. “The use of an alcohol hand rub preparation may be advised in some circumstances to compliment the use of soap and water.” (Guidelines for Infection Prevention and Control in the Community.” (January 2006). No action has been taken in this respect. Gravesham Place Integrated Care Centre DS0000067174.V345221.R01.S.doc Version 5.2 Page 18 The manager erroneously confirmed on the AQAA form that the home had used the Department of Health guide Essential Steps to assess the current infection control management. Such an audit should now be carried out. Gravesham Place Integrated Care Centre DS0000067174.V345221.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, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitably trained staff are available to meet residents’ needs. Some residents commented that at times the staffing levels are insufficient. Recruitment procedures have improved thus ensuring that the residents are in safe hands. EVIDENCE: The manager and senior staff confirmed that there are sufficient staff on duty to meet residents’ care and nursing needs at all times. However, several relatives and residents commented that, at times, residents have to wait a long time to be attended to. It is recommended that staffing levels be constantly reviewed. At the previous inspection visit it was recorded that the nursing unit has 24hour nurse cover. However, the night nurse is also responsible for providing advice and assistance for the other units. This arrangement may result in a possible absence from the unit, which would therefore not have a guaranteed Gravesham Place Integrated Care Centre DS0000067174.V345221.R01.S.doc Version 5.2 Page 20 24-hour cover. At this inspection visit it was noted that no change has been made with this arrangement. The centre provides accommodation to residents of differing ethnicity. Several staff are able to communicate with the residents in their own language. Care and administrative staff are directly employed by the home but nurses have a contract with the PCT. Grosvenor Facilities provides maintenance, laundry, cleaning and catering staff. The previous inspection visit confirmed that good staff recruitment procedures are in place. No staff records were examined at this inspection. All staff receive statutory training updates. Over 50 of the staff have an NVQ qualification. Training records in the managers’ office evidence recent staff training, which includes NVQ, adult protection, medication, diabetes and dementia awareness. The team leader spoken with in the dementia care unit said that dementia care training had improved and that further training was scheduled. Gravesham Place Integrated Care Centre DS0000067174.V345221.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, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager endeavours to run the home in the best interests of residents and staff are well supervised. A system is in place ensuring that residents’ monies are safeguarded. Staff are well supervised. Residents’ health and safety must be improved in respect of infection control practices, safe access and fire safety in some areas of the home. Gravesham Place Integrated Care Centre DS0000067174.V345221.R01.S.doc Version 5.2 Page 22 EVIDENCE: The registered manager has over 20 years previous experience in residential and day care for older people and an additional ten years experience in social and health care settings. She has a certificate in management and has been awarded the registered manager’s award. She is assisted by two senior team leaders and 9 team leaders, which include registered nurses. It is evident that the manager endeavours to provide a quality service. However, some of the requirements of this report in relation to safety are outside her remit and in that respect her hands are tied. The AQAA completed by the manager states, “Being facility managed has been a barrier to improve as much as we would have liked”. Residents’ meetings on each unit and staff meetings within the home are held on a regular basis. The quality assurance system includes residents’ satisfaction questionnaires sent out annually. An annual review is to be carried out that includes feedback from residents, their representatives and health and social cares professionals. In view of comments received following this inspection, the centre may wish to ask for feedback more frequently. Residents are encouraged to manage their own personal allowance. It this is not possible, the centre can arrange for a Personal Property Account to be opened. 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 a PCT clinical specialist nurse. The manager provides supervision to nurses regarding managerial issues. Care staff are provided with supervision from either a team leader or a nurse depending on which unit they work. Grosvenor Facilities is responsible for regular testing and maintenance of equipment and facilities within the home. A relative raised the difficulties encountered in gaining access to the centre through the ring call facility. “ It would appear to rely totally on a member of staff having the time to respond and answer the call.” This issue was discussed with the manager. Records of accidents and incidents are recorded appropriately. In respect of providing a safe environment for the residents, three safety issues remain outstanding. See standards 14, 19, and 26. Gravesham Place Integrated Care Centre DS0000067174.V345221.R01.S.doc Version 5.2 Page 23 Gravesham Place Integrated Care Centre DS0000067174.V345221.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 3 x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 2 x x x x x 1 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 1 Gravesham Place Integrated Care Centre DS0000067174.V345221.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement That care plans fully reflect all changing health and social care needs of the residents That care plans be completed in sufficient detail to evidence that residents ‘needs are met Previous time scale of 15/04/07 not met That care plans be reviewed as needs change That suitable activities are provided for residents in the dementia care unit. That a urgent review takes place regarding the safety of the upstairs balcony to ensure that residents with dementia are protected Previous time scale of 22/11/06 not met. That universal precautions be provided in residents’ bedrooms That residents have a choice as to whether they keep their DS0000067174.V345221.R01.S.doc Timescale for action 30/09/07 2 3 OP12 OP19 16(2) (n) 13 (4) 30/09/07 30/09/07 4 5 OP26 OP38 OP19 OP14 13(3) 23 (4) c (i) 30/09/07 30/09/07 Gravesham Place Integrated Care Centre Version 5.2 Page 26 bedroom doors open or not, while at the same time complying with the fire regulations 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 OP1 Good Practice Recommendations That the Service User Guide be updated Gravesham Place Integrated Care Centre DS0000067174.V345221.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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Gravesham Place Integrated Care Centre DS0000067174.V345221.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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