Inspection on 13/12/05 for Grays Court

This inspection was carried out on 13th December 2005.

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

Grays Court 08/05/07

Grays Court 06/12/06

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

CARE HOMES FOR OLDER PEOPLE Grays Court Church Street Grays Essex RM17 6EG Lead Inspector Mrs Nikki Gibson Unannounced Inspection 13th December 2005 10:00 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 Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 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. Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Grays Court Address Church Street Grays Essex RM17 6EG 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) 01375 376667 01375 397497 Minster Care Management Limited Mrs Charlotte Mary Dean Care Home 87 Category(ies) of Dementia - over 65 years of age (52), Old age, registration, with number not falling within any other category (87) of places Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection First Inspection with new company Brief Description of the Service: Grays Court Care Home provides personal care and accommodation for eightyseven older people of whom up to fifty two may have a diagnosis of dementia. The home is purpose built and is designed round a central courtyard, which provides an attractive garden area with seating. Accommodation is provided on two floors and is divided into four units. Each unit is self contained with small kitchen for snacks, dining room and lounges. There is ample space with small lounges, which can be used for a variety of activities. All bedrooms have spacious en-suite facilities. There is a small shop on the premises for resident’s use. The home has an designated activity room with attractive displays and a busy activities programme. The Grays Court is within easy reach of trains, buses and local facilities. Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection, which lasted eight and a half hours and was undertaken by two inspectors; Lead inspector Nikki Gibson was accompanied by Regulation Inspector Sarah Buckle. During the inspection there was a tour of the premises and records and documents were looked at. Time was spent observing care in the lounges and dining rooms. Five residents were spoken to about life at Grays Court. One visitor, the manager, deputy manager and six members of care and domestic staff were also spoken with. The proprietor, manager, staff, and residents were most helpful and this was greatly appreciated. Discussion of the inspection findings took place with staff throughout the inspection and guidance and advice was given. Feedback was given to the manager and proprietor at the end of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Residents and their families and friends need to be provided with more written information about the home. More consideration needs to be given on how Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 Page 6 and where residents with dementia spend their day. Records and documentation about the residents and their needs must be improved so that their needs can be met consistently. The use of space in the home needs to be reviewed so that residents have access to their bedrooms at any time and so that all mealtimes can be taken in comfort. Many areas of the home would benefit from being refurbished including some lounges and bathrooms. Staffing levels and skills mix need to be reviewed to ensure that adequate staffing levels including senior staff are on duty in all units on every shift. The home needs to develop a system of checking that a high standard is maintained in line with the homes Statement of Purpose. 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. Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 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 Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 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, 6 Information about the home needs to be provided directly to interested parties so that informed choice can be made. Further guidance and training is required so that staff are able to meet the specialist needs of residents with dementia. EVIDENCE: A copy of the most recent report and the homes Statement of Purpose and Service User Guide were displayed in the entrance hall. A relative visiting the home said that she had not been given any of these documents and she had chosen the home after being shown round. She said she instinctively liked the atmosphere but would still like to see written information about the home. The Statement of Purpose should be provided for all residents and prospective residents and/or their supporters. The manager said that she undertakes a full assessment prior to offering a place in the home. She says she prepares before the visit to ensure she is able to communicate with the prospective resident as effectively as possible. Preadmission assessment forms are stored separately to the care plan and were not inspected on this occasion. Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 Page 9 The home is registered to care for a high number of people with dementia who are accommodated in to two large units. This poses a considerable challenge to the proprietors and staff. At the time of the inspection it was assessed that the specific needs of some residents with dementia were not being met. A review of care practices and the environment is required. Additional staff training has started and has been welcomed by staff. It is hoped that this will be continued after the Christmas period. During the inspection seventeen residents with dementia were observed sitting on chairs round the edge of a room. The room lacked any form of stimulation apart from a television and radio both of which were on. No staff were in the room engaging with the residents. Later staff entered the room and took people out to the toilet, however interaction was very limited. A visitor to the home also commented on the lack of appropriate stimulation for residents with dementia. One resident with dementia was presenting some challenging behaviours. These were being recorded but with no name of staff involved, no date or time and without a full description of the incident they would be of very limited use. Also some of the comments recorded were considered judgmental and unhelpful. Grays Court does not provide intermediate care. Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 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 Staff were knowledgeable about the residents however this was not adequately recorded to ensure consistency of care. Due to poor recording good health care could not always be evidenced. Shortfalls in the medication procedures meant that medication was not always administered correctly. Lapses in confidentiality on notices meant that residents’ privacy was not always respected EVIDENCE: Five care plans were studied. It was noted that due to the format that staff had restricted space to record information. There was little on each file to tell staff about the history of the resident. This is an important aspect of care of people with dementia. The quality of the care plans varied. When talking to some staff they were clearly knowledgeable about the residents and their needs but this was frequently not recorded. This could lead to inconsistency of care and residents not getting their needs met. Comments were recorded such as: ’teeth no longer fit’, ‘not as cheerful as she used to be’, ‘son wants physio to visit’ ‘not eating as well as she did’ however there was no evidence if any of these were followed up. Care plans were not dated or signed so it was not possible to know if the information was up to date or who had recorded it. There was no evidence of the resident or their supporter being involved in Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 Page 11 drawing up the care plan. Care plans were not being reviewed monthly. One care plan had only been reviewed three times in the past year. One resident was noted to have lost 1 stone in four months however his nutrition risk assessment states he was at low risk and there was no care plan to cover his specific nutritional needs. The daily notes were repetitive and showed a lack on insight in to the needs of residents with dementia. They showed a lack of intervention by staff for residents who wander or spend the day sitting in one chair. For most residents with more advanced dementia only the food eaten had been recorded. One resident with a history of pressure sores and at very high risk of developing them again had not been reviewed for the past six months. Residents had tick charts for bowel movements and personal care, which were completed erratically and gave a picture of poor care, which was not necessarily the case. The manager said that there are plans to review the care planning system with the support of the area manager who is knowledgeable in the care of people with dementia. Medication procedures were studied on one unit. The medication trolley was over filled and additional medication storage is required to enable staff to administer medication safely. In general appropriate procedures were being followed. There was a list of staff who have been authorised to give medication and their approved initial. There was a photo of each resident on their Medication Administration Record (MAR) sheet. Where the MAR sheet is handwritten it must have the same information as on the packaging and it must be signed and dated by the person transcribing and ideally counter signed. For each medication which has been prescribed to be given ‘as required’ (PRN) there must be a protocol to ensure all staff are aware of what it was prescribed for and when it might be needed. Patient Information Leaflets were not readily accessible for all medication. One drug ‘Fosimax’ was not being given appropriately. On the blister pack is stated ‘follow printed instruction carefully’, however staff were unaware of the correct procedure and were unable to access the instructions. All the guidance given on medication at the inspection can be found in the Royal Pharmaceutical Society of Great Britain guidelines for ‘The Administration and Control of Medicines in Care Homes and Children’s Services’. A copy can be obtained by contacting 0207 572 2409 or e-mailing: ifearon@rpsgb.org.uk Information about residents in notices and on white boards compromises the residents right to privacy and dignity. The lack of any cupboards in en-suite facilities requires residents to have all personal items on display including incontinence aids. Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 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 In some areas activities and mealtimes are a very positive experience for the residents, however in other parts of the home they are of a much poorer standard. There are suitable lounges and facilities for visitors who are made welcome. EVIDENCE: The home has a very well equipped activities room and three designated members of staff covering 70 hours per week for the 82 residents. Displays in this area of the home are well presented and there are some excellent reminiscence props. Residents’ craftwork is displayed in the corridors and they have won a prize at a local show. The home is right to be proud of the work of those who provide activities, entertainment, and trips out. Unfortunately it has become commonplace in the home for all activities, stimulation and social interaction to be considered the responsibility of the activities coordinators. All staff need to consider this an important part of their role. Mental stimulation and purposeful activities are an integral part of good care practice. It is not an optional extra for those residents who are able to make the choice to spend time with an activities co-ordinator. Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 Page 13 On the dementia units there was little evidence of purposeful pastimes taking place. There were no hobbies, games, equipment, plants, photographs, pictures, books, or magazines etc. Bedroom doors were locked so that residents did not have access to objects in their bedrooms. In the main lounge chairs were in tight rows against the walls with no room for coffee tables or space for staff to sit with the residents. A number of the residents with dementia may wander or pace the corridors. The reasons for this need to be explored. Alternatives to locking the bedrooms need to be considered. The home may wish to obtain further advice on appropriate activities for the elderly from the National Association for Providers of Activities for Older People on 01376 585225 Email: tessatnapa@aol.com Residents can have visitors at any time and they are encouraged to feel at home and make use of the facilities. Residents’ views on the food varied from ‘lovely’ to ‘poor’. The dining room for the large dementia unit was over crowded and the tablemats were worn and old. Staff said that there are plans to use two rooms and this needs to be pursued to ensure that residents can eat in comfort. In another unit the tables were attractively laid with flowers and cruet and bottles of sauce. No separate nutrition records were seen, however what residents had eaten was written in their daily notes. One resident was noted to have been weighed three times in the past five months and to have lost three stone. It is a concern that there was no evidence of any staff interventions or referral. Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 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. The home has addressed a recent complaint well and to the satisfaction of the complainant. EVIDENCE: One relative who has complained in the past said that communication with the home was much improved. She was particularly unhappy that her relative had fallen and she had not been informed. However she said that the staff group are now ’lovely, and supportive’. Complaints were recorded in a book and ways to simplify the system were discussed. The home has received three complaints in the past year and none since the new registration in September 2005. The complaint policy was displayed in the entrance hall. Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 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 The premises are clean and spacious but are not used and maintained to the best standards. An action plan is due of the improvements to be made with time scales for completion, which was part of the registration agreement. EVIDENCE: The ‘Ballroom’ is used for entertainers, staff training, visitors and large group activities. It suffered from smoke entering from the connecting residents smoking room. An area off the ballroom is used for storage and was unsightly and a hazard to residents and access needs to be restricted possibly by fitting doors. Prior to the present proprietors taking over, the premises had been neglected. Furnishings and décor in most of the home are now in a poor condition. There used to be excellent displays on the corridors these are now torn, defaced and are now in need of replacing. Some bathrooms and toilets are clinical, kitchenettes need refurbishment, carpets are stained and armchairs are stained with black and shiny arms. As part of the registration process Minster Care Management Ltd agreed to provide for the CSCI within the first three Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 Page 16 months a development plan detailing any necessary and proposed action to be taken by the company to improve or modify the environment. This development plan is now due and improvements need to be underway. Throws had been used in one lounge to cover the worn chairs, however they could be confusing for residents with dementia who may no longer recognise them as armchairs. There is a small high dependency residential unit where half the residents require the assistance of two carers. Two electric hoists being charged in the corridor posed a hazard and detracted from the homely feel of the unit. The carpet in the lounge although recently cleaned was very badly stained and needs to be replaced. The home has a shop, which is run by a volunteer. Residents, staff and visitors can buy the toiletries and sweets that are on sale. This is a lovely feature of the home. Each unit has its own kitchenette which relatives and residents who are able to are encouraged to use. This is an excellent facility, which increases choice and independency for residents. It also provides a homely focal point on each unit. It was clear that the home were making efforts to provide a homely environment unfortunately this was detracted from by the over use of instructions for staff and information about residents which were displayed on the walls. Some doors are colour coded to help orientate residents however signage was poor and each corridor had rows of unmarked bedroom doors. This had led confused residents to wander into the wrong bedrooms, to address this staff had locked all the bedroom doors. This is not considered good practice and all alternative options should be considered. A number of bedrooms were inspected at random and all were clean and odour free. The new rooms were in use, however they were not finished and lacked armchairs, light shades, bedside lights, lockable facilities, table, bathroom storage cupboards, mirrors. It was noted that a new residents room had not been personalised and she appeared very short on clothing. Staff said that the home would be an advocate for the resident and ensure that this was rectified. By each hot water outlet in every bathroom and bedroom were sheets where water temperatures had been recorded this is an inappropriate place for them to be kept. The records showed that temperatures are checked infrequently even when they fell outside the acceptable temperature range and advice was given. Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 Page 17 Advice on preventing Legionella can be obtained from the following sources. Booklets Essential information for providers of residential accommodation and A guide for employers are available free for single copies from 01787 881165 or HSE Books, PO Box 1999, Sudbury, Suffolk. CO10 2WA, fax 01787 313995 Website www.hsebooks.co.uk Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 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 Staffing levels and skills mix needs to be amended inline with the increase in numbers of people with dementia. Staff training in the specific needs of residents with dementia is to take place. Recruitment procedures are good. EVIDENCE: The home is divided into four separate units each of which needs to have a senior member of staff on duty at all times. Staff spoken to said that the senior’s role is very pressured. They said that training on dealing with visitors and staff would be beneficial. Other staff said that it was very busy on the larger dementia unit in the afternoons due to the needs of the residents and the layout of the unit. There has been an increase in the number of dementia beds. The required staffing level now is: 1 senior and 3 care staff in the 20 bedded residential unit 1 senior and 2 care staff in the high dependency 10 bedded residential unit 1 senior and 3 care staff on the 23 bedded dementia unit 1 senior and 4 care staff on the 29 bedded dementia unit. In addition the manager and deputy are supernumerary. There are adequate catering and domestic staff. Three activity co-ordinators cover seventy hours in the home. Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 Page 19 A drop in staffing levels in the afternoon is not considered appropriate, as residents’ needs remain the same. In the small residential unit staff said that assisting a resident to use the commode can take two staff twenty minutes therefore a minimum of three staff are required throughout the day. The home needs to increase the number of staff experienced, trained and competent to undertake the seniors’ role and ensure that there is one on each unit on every shift. The staff and home are committed to undertaking training. In date staff training certificates for Elder Abuse, Health and Safety, First Aid were displayed on the wall. The manager said that fifteen members of staff had NVQ level 2 in Care and 25 members of staff are in the process of training. The Home and manager would benefit from having a staff training matrix. This would enable them to know quickly what percentage of staff had NVQ training and ensure that there was an adequate training and skills mix on duty in each unit and know where there was a training need within the home. Staff recruitment records were inspected and showed that robust procedures were being followed which protected the residents. Staff induction training is being improved. All new staff will use the new induction programme and there are plans for other staff to have the opportunity to undertake this training as a refresher course. Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 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, 32, 33, 37 The home has been run well by the manager during the period of a change in ownership. The new proprietors need to invest in the home to raise standards and meet their Aims and Objectives as set out in the Statement of Purpose. EVIDENCE: The manager is in the process of completing the NVQ level 4 in Care she said she has plans to continue developing and refreshing her knowledge and competency. The manager has also recently completed a two day Moving and Handling Training for Trainers course. The home has gone through the upheaval of a change of registered provider. The manager has coped well and maintained the morale of staff. Staff meetings take place and some are scheduled to suit the night staff. Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 Page 21 A quality assurance system needs to be in place, which monitors and assesses if the home is meeting its aims and objectives and complying with its own statement of purpose. Residents views must be obtained and a report written and published with copies sent to the CSCI. Each month there should also be an unannounced visit by the responsible individual who prepares a written report on the conduct of the home with copies provided to the manager and the Commission for Social Care Inspection. In general records were well maintained and appropriately stored. Any shortfalls or advice given is already detailed in this report. Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 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 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 3 3 2 3 2 2 X STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X X 2 X Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 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(1) Requirement The registered person must supply a copy of the Statement of Purpose to each resident and/or their representatives. The registered person must promote and make proper provision for the care, welfare and supervision of residents. This refers to the home making amendments to meet the specialist needs of residents with dementia. The registered person must ensure that care plans have sufficient detail to provide clear guidance to staff on the actions to be taken to meet the residents health and welfare needs and must be drawn up with the involvement of the resident and/or their representative. Care plans must be kept under review. The registered person must maintain a record of incidence of pressure sores and of treatment provided to the resident. The registered person must make arrangements for the DS0000065444.V272904.R01.S.doc Timescale for action 10/02/06 2 OP4 12(1) 10/02/06 3 OP7 15(1) 10/02/06 4 OP8 15(2) Schedule 3 13(2) 10/02/06 5 OP9 10/02/06 Grays Court Version 5.0 Page 24 6 OP10 12(4) 23(2)(m) 7 OP12 12(4) 8 OP15 16(2) 9 OP19 23 10 OP22 16(1) 11 OP24 16 12 OP25 13(4) 13 OP27 18(1) recording, handling, safekeeping, safe administration and disposal of medicines received into the home. For details of the shortfalls see report. The registered person must ensure that the home is conducted in a manner that respects the privacy and dignity of residents. This refers to public notices and lack of storage The registered person must consult with residents about their interests and provide a programme of activities including those suited to people with dementia. The registered person must ensure that all residents have the opportunity to eat their meals in pleasant surroundings The registered provider must produce an action/development plan detailing the improvements to be made to the environment, which was part of the registration agreement and is now over due. The registered provider must ensure that equipment is appropriately stored and the environment is adapted to meet the needs of the residents including clear signage. The registered person must provide in rooms occupied by residents adequate furniture and equipment suitable to the needs of the resident. (See NMS 24 for guidance) The registered person must ensure as far as possible the safety of service users, this refers specifically to the regulating of water temperatures The registered person must ensure that at all times there are suitably qualified, competent, DS0000065444.V272904.R01.S.doc 10/02/06 10/02/06 10/02/06 10/02/06 10/02/06 10/02/06 10/02/06 10/02/06 Grays Court Version 5.0 Page 25 14 OP33 26 15 OP33 24 and experienced persons working at the Home in such numbers as are appropriate for the health and welfare of the residents See report for details. The registered person must prepare a written report, as detailed in this regulation, on the conduct of the Home and supply a copy to the manager and the CSCI at least once a month The registered person must maintain a quality assurance system for reviewing and improving the quality of care provided 10/02/06 10/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP14 OP15 Good Practice Recommendations Alternative arrangements should be made so that residents can have access to their own rooms and possessions at any time. All residents should have their meals in pleasant surrounding which are not over crowded. Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Grays Court DS0000065444.V272904.R01.S.doc Version 5.0 Page 27 - 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. 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