Inspection on 07/03/07 for Gravesham Place Integrated Care Centre

This inspection was carried out on 7th March 2007.

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

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

Other inspections for this house

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... 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 7th March 2007 10:45 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.V328508.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.V328508.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.V328508.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1 2 3 4 7 of the 20 elderly dementia care beds may be used for service users aged 55 years and over 3 of the 20 older people beds may be used for service users aged 55 years and over for rehabilitative care. 20 beds are provided for people requiring nursing care 20 beds are provided for older people Date of last inspection 13th October 2006 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. 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 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.V328508.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 7th March 2007 and comprised discussions with the manager, nurse in charge and team leader. Visits were made to the nursing and dementia care units. A number of residents, a visiting relative and care staff were spoken with. A partial tour of the building was made. Samples of care plans and staff files, complaint records and other documentation were examined. Comment cards were left for 8 residents and two care managers to complete. Seven residents and one care manager responded. Comments made are referred to in the report. Since the visit of 13 October 2006, a number of complaints have been investigated under adult protection procedures. The outcome of these has yet to be concluded. What the service does well: Following the first inspection on 13 October 2006, the centre submitted a time scaled improvement plan in response to outstanding requirements. Some of these have been acted upon. As a result, risks to residents have been reduced. Prospective residents are assessed to ensure that the centre can meet their needs. Residents said they are content and happy in the centre. They like the staff and were able to visit before they moved in. Residents are treated with respect. Residents receive a varied diet. Residents live in a clean, tidy and well-maintained environment. The manager runs the centre in residents’ best interests and is committed to providing a quality service. Residents are provided with opportunities to air their views. Appropriately supervised staff are available in sufficient numbers to meet residents’ needs. Residents are protected from potential abuse. Gravesham Place Integrated Care Centre DS0000067174.V328508.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The improvement plan dated 4 January 2007 stated that workshops would be facilitated to ensure that staff receive care-planning training. Such workshops have been set up for 28 and 29 March 2007. Care plans would benefit from a standard format and more comprehensive reviews. The recording of the provision and participation in social activities should be included particularly in the dementia care unit. Improvements could be made to the quality of the daily records. Residents are better protected by the procedures for the administration of medication but these must be further improved. The previous inspection required that residents 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 yet been addressed. The centre must ensure that residents in the dementia care unit are provided with suitable activities. The centre must introduce a robust system of dealing with complaints. In order to protect residents from the risk of infection, the centre must ensure that staff are provided with appropriate hand wash facilities such as liquid soap and paper towel dispensers as well as a foot operated bin. The improvement plan dated 4 January 2007 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. Gravesham Place Integrated Care Centre DS0000067174.V328508.R01.S.doc Version 5.2 Page 7 Residents still do not have freedom of access to this space due to the risks involved. The environment would benefit from making it look more homely with pictures, features and colour, this again was an issue when the unit was registered and assurance were made at the time that this would be done. 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.V328508.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.V328508.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 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. EVIDENCE: The centre updated its statement of purpose and service user guide in November 2006. Whilst the arrangements for ascertaining residents’ views are referred to in the statement of purpose, it is not mentioned in the service user guide. Information re additional charges made for toiletries, chiropody, newspapers and some outings should also be made available to residents. The manager said this would be included in future. Prospective residents are assessed before they move in, in order 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. Gravesham Place Integrated Care Centre DS0000067174.V328508.R01.S.doc Version 5.2 Page 10 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 also provides short-term respite and rehabilitation care. These units were not inspected on this occasion. 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.V328508.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and social care needs are not fully reflected in their care plans or comprehensively reviewed. They are not fully protected by the procedures in place for the administration of medication. 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. The format was muddled and information difficult to find. In the dementia care unit, insufficient information was recorded about residents’ likes and dislikes. Such information should inform the activities provided. It is recommended that, wherever possible, a Life History be obtained. It is further recommended that the daily record reflect how the social needs of the residents are met. As identified in the previous inspection report, care reviews should be more comprehensive as these are currently recorded as a date only. Gravesham Place Integrated Care Centre DS0000067174.V328508.R01.S.doc Version 5.2 Page 12 Care-planning workshops have now been set up for 28 and 29 March 2007. 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. The centre is awaiting the arrival of suitable medication trolleys and has introduced safe interim measures for the administration of medication. Staff sign for medication administered but must ensure that all hand written entries are countersigned. Since the previous inspection, systems have been introduced to ensure appropriate disposal of waste medication. However, the centre must ensure that bins provided are labelled correctly, that additional systems are provided for the safe disposal of controlled medication and that records of all disposals are maintained. Finally, the centre must develop a policy and procedure for the safe disposal of medication. A care manager wrote, “The centre provides a very caring environment”. A visiting relative said that staff are kind, courteous and helpful. 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. See also standard 19. Gravesham Place Integrated Care Centre DS0000067174.V328508.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 could be improved. Not all residents can exercise choice and control over the lives. Residents are able to keep in contact with their family and friends and they receive a varied diet. EVIDENCE: Residents have a choice of activities within the centre. Two activities coordinators are employed, who provide art and craft, sewing, knitting and handicrafts. Staff also undertake activities with residents, such as softball and memory games. The manager said that she has put in an order for sensory features and equipment on the dementia care unit. Such “snoozelem” equipment would be provided in the quiet lounge and would enhance the activities currently available to the residents. Some residents are supported to go shopping and others attend day services within the centre complex, which provide a variety of activities. The centre Gravesham Place Integrated Care Centre DS0000067174.V328508.R01.S.doc Version 5.2 Page 14 provides accommodation to residents of differing ethnicity. See also standard 27. Residents are able to make some choices within the constraints of group living and their own abilities. Currently those residents whose rooms are situated in link corridors cannot have their bedroom doors open due to fire procedures. The manager said that this situation has not yet been resolved. Residents in the dementia care unit have access to an enclosed roof garden. However, residents cannot freely access a balcony without staff support, as this area is unsafe. This has been an issue since registration of the centre and it is of concern that it hasn’t been resolved yet. 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. A relative said, “ I visit most days and know all the staff. “ The catering service and staff 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. Residents said they enjoyed the variety of the meals. However, the following additional comments were received: “There is too much chicken”, “Food is not always cooked to my liking as e.g. the vegetables are too hard and the pastry not nice”, “I would like more gravy”, “Breakfast and lunchtime meals are too close together”. These comments were discussed with the manager. Gravesham Place Integrated Care Centre DS0000067174.V328508.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 adequate. This judgement has been made using available evidence including a visit to this service. The views of residents and their representatives are listened to. There is however insufficient evidence of the action taken to remedy any concerns. Residents are not wholly protected from abuse as a number of adult protection referrals have been made. EVIDENCE: Since the previous inspection, the centre’s written complaints procedure has been updated and now includes details of the CSCI and timescales for action after a complaint is received. Residents are at ease talking with staff who listen to their concerns. Regular residents’ meetings are held to welcome views and concerns. Whilst these are recorded, the centre must ensure that the action taken is also recorded and that the complainant is satisfied with the action taken. Procedures and staff training ensure that residents are protected from potential abuse. Gravesham Place Integrated Care Centre DS0000067174.V328508.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 adequate. 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.V328508.R01.S.doc Version 5.2 Page 17 The centre would benefit from some ”homely features” as currently it looks a bit stark. This issue was discussed with the manager and it is of concern that this issue, having been discussed at registration, has still not been resolved. All residents accommodated on each unit of the centre have access to outside areas, such as gardens, a balcony and a roof terrace. At the previous inspection, it was again identified that the surrounding railing and panel of a balcony is unsafe for residents without direct staff supervision. The improvement plan dated 4 January 2007 states that that the arrangement would be reviewed. This issue was raised at registration and the commission was assured at this time that the matter would be resolved. At this visit such a review had yet to be undertaken. It is of concern that despite these assurances no action has been taken. The manager confirmed in writing on 22 November 2006 that canopies, to maintain residents’ privacy from windows overlooking the balconies, have been ordered. Again this was raised at the point of registration and it is disappointing that it took so long for any action to be taken. The garden is well designed and has disabled access. It 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. Since the previous visit, 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. See also standard 38. All the areas of the home seen were clean and tidy. Since the previous visit, a lock has been provided to the sluice door in the dementia care unit thus ensuring residents’ safety. Staff must ensure that sluice rooms are clutter free to allow for effective cleaning. Residents are provided with en-suite facilities. However, 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). Gravesham Place Integrated Care Centre DS0000067174.V328508.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 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 in sufficient numbers to meet residents’ needs. 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. The centre is still in the process of recruiting more staff and relies on agency staff for current shortages. The nursing unit has 24-hour 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 24-hour cover. This issue was discussed with the manager after the visit who said the matter would receive her attention. The centre provides accommodation to residents of differing ethnicity. Several staff are able to communicate with the residents in their own language. However, a resident responded to the question do staff listen and act on what you say with, “there is a definite language barrier at times.” Gravesham Place Integrated Care Centre DS0000067174.V328508.R01.S.doc Version 5.2 Page 19 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. A sample of staff files of recently recruited staff confirms that the centre takes up references and explores candidates’ full employment history. All staff receive statutory training updates. Training records in the managers’ office evidence recent staff training, which includes NVQ, adult protection, medication, diabetes and dementia awareness. However a care manager commented that “there appears to be a lack of training in the dementia care unit and staff don’t seem to have the knowledge to deal with different personalities of this client group”. This issue was discussed with the manager following the visit. Gravesham Place Integrated Care Centre DS0000067174.V328508.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36, 38 Quality in this outcome area is adequate. 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. Residents’ health and safety must be improved in respect of infection control practices. 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. She has a certificate in management and has been awarded the registered manager’s award. Gravesham Place Integrated Care Centre DS0000067174.V328508.R01.S.doc Version 5.2 Page 21 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. 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. Records of accidents and incidents are recorded appropriately. As stated in standard 26, infection control practices must be improved in respect of hand wash facilities for staff. Grosvenor Facilities is responsible for regular testing and maintenance of equipment and facilities within the home. At the previous visit, records pertaining to such maintenance could not be located. The availability of such records has been monitored and senior staff have been made aware of their location. Gravesham Place Integrated Care Centre DS0000067174.V328508.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 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 2 x x x x x 1 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x x 3 x 2 Gravesham Place Integrated Care Centre DS0000067174.V328508.R01.S.doc Version 5.2 Page 23 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 22/11/06 not met That care plans be reviewed as needs change 2 OP9 13(2) That handwritten entries on medication administration records be countersigned by a second member of staff That records of disposed of medication be maintained That systems be introduced for the safe disposal of controlled medication 3 OP16 22 That a robust system of dealing with complaints be devised 15/04/07 15/04/07 Timescale for action 15/04/07 Gravesham Place Integrated Care Centre DS0000067174.V328508.R01.S.doc Version 5.2 Page 24 4 OP19 13 (4) That a 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. 15/04/07 5 OP26OP38 13(3) That universal precautions be provided in residents’ bedrooms 15/04/07 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 3 Refer to Standard OP1 OP12 OP14 Good Practice Recommendations That the Service User Guide include how residents’ views are to be sought and additional charges made That activities provided for residents in the dementia care unit be enhanced That residents have a choice as to whether their bedroom doors are left open or not, whilst at the same time complying with fire regulations Gravesham Place Integrated Care Centre DS0000067174.V328508.R01.S.doc Version 5.2 Page 25 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.V328508.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!