Inspection on 08/05/07 for Grays Court

This inspection was carried out on 8th May 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

Grays Court 06/12/06

Grays Court 13/12/05

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 Michelle Love Unannounced Inspection 8th May 2007 08:00 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.V338928.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. Grays Court DS0000065444.V338928.R01.S.doc Version 5.2 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.V338928.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th December 2006 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 residents and staff use. The home has a designated activity room with attractive displays. The Grays Court is within easy reach of trains, buses and local facilities. The email address is grayscourtcarehome@msn.com The most recent inspection report was readily available in the entrance hall of the home. The pre inspection questionnaire details that the weekly fees for residents range from £350.00 to £510.00. Additions costs incurred relate to hairdressing, chiropody, newspapers, toiletries, cigarettes, confectionary, taxis and reflexology. Grays Court DS0000065444.V338928.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine `key` unannounced inspection conducted by Michelle Love and Bernadette Little, Regulation Inspectors over a period of 11 hours. As part of the inspection process a tour of the premises was undertaken and a random sample of records pertaining to care planning, healthcare documentation, staff recruitment, training, complaint records and policies and procedures and medication were examined. Case tracking was undertaken in relation to nine residents living at Grays Court at that time. During the site visit, a number of relatives and visiting professionals were asked to complete a survey so as to inform inspectors of the care and quality of service provided at the care home for their client or member of family. Comments from these surveys and records of actual discussions have been incorporated into the main body of the report. Other reports and correspondence provided by the registered manager and registered provider were also used as evidence to inform this report. Additionally time was spent observing care practices, observing the lunchtime and teatime meal provided to residents and talking to both care staff, senior staff, the management team and residents. Feedback of the findings from the inspection were discussed with both the registered manager and registered provider. What the service does well: What has improved since the last inspection? Grays Court DS0000065444.V338928.R01.S.doc Version 5.2 Page 6 Staffing levels and the deployment of staff within the home have been maintained for the benefit and well being of residents. Lounge areas were well staffed throughout the site visit and call alarms were answered promptly. The homes care planning processes continue to improve, despite some continued issues relating to risk assessments. Care plans were easy to follow and evidenced residents care needs and staff interventions provided. There was clear evidence to indicate that residents and/or their representatives had been consulted. The registered manager has worked very hard to raise the standard of care within the home and to address previous identified shortfalls. It is evident that her hard work and management of the home has resulted in a continued decrease of statutory requirements and positive comments from residents, relatives and other interested parties. The latter can be evidenced from comments incorporated into the main body of the report. What they could do better: 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. Grays Court DS0000065444.V338928.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Grays Court DS0000065444.V338928.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good system for ensuring that admissions are not made until a full needs assessment has been undertaken. Admissions to the home only take place if the registered provider is confident that it has the skills and services to meet the assessed needs of the prospective resident. EVIDENCE: On inspection of four care files for the newest residents, all were noted to have a pre admission assessment completed. Assessments were seen to be satisfactory and in addition to the homes pre admission format, the home had received information and/or assessments carried out through care management arrangements and healthcare trusts. It was positive to note that there was information recorded to evidence that both the resident and/or their representative had been involved within the pre admission assessment process Grays Court DS0000065444.V338928.R01.S.doc Version 5.2 Page 9 and that opportunities had been offered for interested parties to visit the care home prior to admission. The home does not provide intermediate care. Grays Court DS0000065444.V338928.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good system for ensuring that the individual resident’s needs are recorded and that there are clear guidelines for care staff to follow so as to ensure consistent and good delivery of care. In general terms the homes medication systems were deemed satisfactory. EVIDENCE: On inspection of a random sample of nine individual care plans these were noted to be detailed, comprehensive and person centred. Care plans were observed to cover all aspects pertaining to individuals healthcare, emotional, physical and social care needs. It was evident that individual care plans examined, were a `working document` and had been reviewed and updated to reflect resident’s changed needs. The registered manager was advised that one element recorded on one persons care plan needed further exploration and this was pertaining to challenging behaviour exhibited i.e. the care plan details that the aforementioned resident presents with both verbal and physical Grays Court DS0000065444.V338928.R01.S.doc Version 5.2 Page 11 aggression. The specific nature of the person’s aggression, possible triggers and guidelines for staff as to how to deal with the person’s aggression/inappropriate behaviours were not recorded. The healthcare records of individual residents were well documented and included staff’s interventions. During the site visit positive comments were received from one community nurse and one district nurse i.e. “excellent communication between district nursing service and this home. I have noticed a vast improvement in the care provided by care staff and a much happier environment. Clients appear well cared for and district nurse requests appear to be met. I have also noted a decrease in staff turnover and put this down to a better working environment and better management” and “things much improved-staffing more appropriate-environment spotless now” and “they are good carers-able to communicate in `good English` with residents and staff monitoring residents well”. In addition one relative stated that the home monitor their member of family healthcare needs and appropriate professionals and services are provided on an as and when required basis. Another relative stated “they have done an admirable job in caring for mum”. A relative survey handed to inspectors recorded “It is a very friendly home-the staff are always helpful, it doesn’t matter what unit you go on the girls are kind, caring and a good laugh”. Eight out of nine care plans included detailed risk assessments. It was disappointing to note that one care plan had no risk assessments devised yet the resident’s care needs related to them being verbally and physically aggressive, being anxious and depressed on occasions, wanders at night/trouble sleeping, communication is limited and is at risk of falls. Despite these minor shortfalls, outcomes for residents were observed to be positive and actual care provided to residents was observed to be sensitive, caring and appropriate. Daily care records for residents were inconsistently documented i.e. some records were detailed and informative whilst others were fairly basic. Records tended to only detail food eaten and provided little evidence of how specifically residents spend their day. The registered manager was advised that daily care records are a good source of evidence to show that care is being provided, as detailed in the care plan. Daily care records when well written help ensure a consistent approach and good quality of care for residents. Detailed daily records will help ensure the registered manager to audit the care being provided to residents, and ensure that staff are following the guidelines in the care plans. It is in the homes interests to be able to show what they have done, along with providing the evidence on which to base the monthly review and to record that they are following the assessment of needs. Medication is stored on both the ground and first floors and was observed to be appropriate. Administration of medication to residents by senior members of Grays Court DS0000065444.V338928.R01.S.doc Version 5.2 Page 12 staff was observed on two occasions and seen to be in line with regulatory requirements and procedures. The home was noted to use the Monitored Dosage System and packets/bottles of medication were signed and dated once opened. The Medication Administration Records (MAR) for all residents were inspected within all four units. A few omissions of staff signatures/initials were noted whereby staff had not signed the MAR record to indicate that medication had been administered to and received by the resident. Both senior staff and the registered manager were advised where MAR records are handwritten, these should be witnessed and signed by two people. An audit of controlled drug medication was undertaken and records and actual medication were noted to concur. Records indicated that at the time of the site visit one resident was prescribed oxygen. A care plan and risk assessment had been devised and was seen to be satisfactory. The homes pre inspection questionnaire which was received at the Commission on 30th April 2007 detailed 21x members of staff are deemed competent to administer medication to residents. The document further details that within the last 12 months staff have undertaken the foundation and advanced Safe Handling of Medication training. Grays Court DS0000065444.V338928.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides an appropriate programme of activities for those people living at the care home. Food provided to residents is varied and of a good quality, and the experience at mealtimes for residents is appropriate. EVIDENCE: On the day of the site visit a copy of the homes activity programme for all four units was provided for inspectors. This details that both group and one to one activities are provided for residents pertaining to crosswords, beauty box, scrabble, puzzles, quiz, `fling a frog`, hoopla, news review, church service, one-to-one, bowls, music quiz, skittles, arts and crafts, external entertainers, bingo, film afternoon, armchair football, board games, table-ball, sing a long and hangman. Several residents spoken with were complimentary of the activities provided. It was positive to note that one resident has been allowed to bring her cat into the care home. Individual residents care plans were observed to detail people’s recreation and social care needs and their personal preferences. Grays Court DS0000065444.V338928.R01.S.doc Version 5.2 Page 14 The home has an open visiting policy whereby residents can receive members of family/friends at any reasonable time. Throughout the day of the site visit many visitors were noted to visit the care home and to see their member of family. The registered manager advised the inspector that several residents have daily visits from family members. The home operates a three weekly menu. On inspection this was seen to be varied and offered residents a choice of cereals and a cooked breakfast each morning, two choices of main meal for both lunchtime and for teatime. In addition to the above, residents have the opportunity to have alternatives to the menu. Inspectors were advised that residents choose their choice of meal the day before. Consideration should be given to alter this practice for those people who have severe confusion/dementia and to devise and implement a pictorial menu. Both the lunchtime and teatime meals were observed to be a positive experience for residents. Staff within each unit was observed to work well as part of a team, the atmosphere during these times was noted to be friendly and relaxed and residents were asked if they liked their meal, if they wanted more and if they had finished. Residents were given a choice of drinks and several residents were noted to have alternatives to the menu (cheese omelette, sausages, sandwich). Comments from residents were complimentary and included “it was smashing” and “that was lovely”. Individual assistance from staff to residents was observed to be sensitive, attentive and it was evident that care staff had a good relationship and rapport with residents and demonstrated a good understanding of individual residents needs. One relatives survey handed to inspectors at the site visit stated “my mother has commented on several occasions about how much she enjoys the food”. Grays Court DS0000065444.V338928.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an appropriate complaints policy and procedure and the registered manger understands how to deal with complaints effectively. There are appropriate policies and procedures in place for safeguarding people who use the service. EVIDENCE: The homes complaints procedure was observed to be displayed and documented within the homes Service Users Guide. The registered manager was advised that the home’s current complaints procedure needs to be updated to reflect that the Commission for Social Care Inspection no longer has any statutory responsibility to investigate complaints. Any complaints received at the Commission will be referred back to the registered provider or to the local authority if they are contractually involved. As part of the inspection process inspectors will examine how the registered provider has dealt with issues and as to whether regulations are being met. The registered manager advised inspectors that the home has received no complaints since the last inspection. A number of compliments regarding the care provided at Grays Court were observed. Grays Court DS0000065444.V338928.R01.S.doc Version 5.2 Page 16 The home was observed to have an appropriate protection of vulnerable adults policy and procedure and to have a copy of the local authorities procedures. At the time of the site visit the home had instigated one protection of vulnerable adults procedure and it was evident that the registered manager had dealt with this in line with policies and procedures and involved the necessary agencies. From discussions with the registered manager, inspectors felt assured that matters would be addressed accordingly. Staff spoken with demonstrated a good understanding of protection of vulnerable adults procedures. The homes training matrix submitted with the pre inspection questionnaire, evidenced the majority of staff have attained training relating to protection of vulnerable adults, however some people’s training needs to be updated. As a result of inspecting a number of care plans, evidence suggested that some residents exhibit challenging/inappropriate behaviours. The training matrix indicates that no staff have received training relating to challenging behaviour. Appropriate measures must be undertaken by the registered provider to ensure that staff receive this training as soon as possible. Grays Court DS0000065444.V338928.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides an environment that is appropriate for the needs of the people who live at Grays Court. EVIDENCE: The care home is well maintained and homely for those people who live at Grays Court. The home is unitised and provides 2x residential units and 2x units for those people with dementia on both the ground and first floors. A random inspection of residents bedrooms revealed these to be personalised and individualised. Much attention and effort has been undertaken to ensure that both dementia units provide a homely communal lounge as well as other space where residents can go and sit quietly, the dining areas are pleasant, there is access Grays Court DS0000065444.V338928.R01.S.doc Version 5.2 Page 18 to a garden, there is a separate activities room and systems are in place to ensure that it is easy for residents to find their own room by way of colour coding and pictures on the door. Each unit is fitted with a keypad for entry and exit. Both units were seen to be bright in colour and fitted with suitable lighting. The homes laundry area was seen to be well maintained and managed. The home was clean, tidy and odour free on the day of the site visit. Grays Court DS0000065444.V338928.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Rosters evidence that the home is staffed efficiently to meet the needs of existing residents who live at the care home. Staff recruitment procedures are generally satisfactory however some gaps were observed. The registered provider recognises the importance of training however there are some gaps in the training programme. EVIDENCE: The registered manager advised inspectors that the staffing levels considered necessary to meet the needs of residents are 1x senior and 3x care staff on one residential unit, 1x senior and 2x care staff on the high dependency residential unit, 1x senior and 3x care staff on one dementia unit, 1x senior and 4x care staff on the other dementia unit during the day and at night a minimum of 1x senior and 1x care staff member on each unit. In addition to the above the registered manager and deputy manager are supernumerary, with additional daily support for domestic and catering duties and designated activities co-ordinators. On evidence of staff rosters these suggested that the above staffing levels are being maintained. Staff spoken with advised inspectors that the ratio of staff to existing residents/dependency levels works in practice. Inspectors’ Grays Court DS0000065444.V338928.R01.S.doc Version 5.2 Page 20 observations supported and confirmed information from staff and the deployment of staff within lounge areas and observations of actual care practices and answering residents call alarms were seen to be prompt and appropriate. A random sample of five staff recruitment files were examined for those people newly employed at Grays Court. Recruitment procedures were seen to be good however some gaps were noted pertaining to only one written reference for two people, one persons written reference received after they commenced employment at the care home, no date recorded as to when one persons POVA 1st was received and no evidence of an induction/evidence of training and qualifications for one person. The staff training matrix was forwarded to the Commission with the homes pre inspection questionnaire. Evidence suggests that all but 6 people working within the home have received fire awareness training, 24x people have received first aid training, 10x people have not received manual handling training, 20x people have not undertaken food hygiene training, only 13x people have received training relating to health and safety, 16x people have undertaken COSHH (Control of Substances Hazardous to Health) training, all but 20 members of care staff/senior staff have received training relating to dementia awareness, 39x members of staff have not received protection of vulnerable adults training and all but one senior member of staff had received medication training. Other training undertaken by some members of staff included epilepsy, catheter care, risk assessments, diabetes, nutrition, diversity and equality and one person has received training relating to creative activities. It is evident that the registered provider is committed to providing training for staff, however gaps were observed in relation to not all staff having manual handling training and a high number of staff not having training relating to protection of vulnerable adults. Further consideration must be made to ensure that specialist training for those conditions associated with the needs of older people are provided. The homes pre inspection questionnaire details that 26x members of staff have NVQ Level 2 or above. Staff spoken with stated that there is a good atmosphere within the home and the staff team work cohesively and closely as a team. Grays Court DS0000065444.V338928.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has the required qualifications, experience and is competent to run the care home. EVIDENCE: There was evidence to suggest that the manager communicates a clear sense of direction, has good people skills and understands the importance of person centred care and effective outcomes for people who use the service. It was positive to note that issues as previously highlighted have in the main been addressed and this is reflective in the number of statutory requirements highlighted at this inspection. Staff spoken with were very complimentary regarding the day to day running of the home and of the homes management. Grays Court DS0000065444.V338928.R01.S.doc Version 5.2 Page 22 On inspection of a random selection of staff files evidence of staff supervision records were available. It was evident that formal supervision has not been conducted in line with regulatory requirements, however the Commission recognises that the registered manager has been without a deputy manager until recently and that there are approximately 90 staff working within Grays Court. The registered manager assured inspectors that a programme of regular staff supervision would be devised and implemented. Records were readily available relating to Regulation 26 visits by the registered provider, records of staff meetings, provider meetings with Thurrock Borough Council and relatives meetings. Regulation 26 reports detailed outcomes of resident surveys, however the findings have not been communicated back to residents and/or their representatives. The registered manager was advised to ensure that the views of other interested parties are also included i.e. GP, District Nurse Services, Hairdresser, Chiropody, Reflexologist etc On inspection of a random sample of individual residents monies/financial records, these were deemed to be satisfactory. Other records inspected related to the homes emergency lighting and alarms, gas and electrical safety inspection certificates, food premises inspection report, employers liability certificate, records for hot water outlets, hoists/slings checked and inspection of the homes fire risk assessment. All were deemed to be appropriate. Grays Court DS0000065444.V338928.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Grays Court DS0000065444.V338928.R01.S.doc Version 5.2 Page 24 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 13(4) Requirement Ensure that risk assessments are devised for all areas of assessed risk and that these are documented within individual residents care files. Ensure that appropriate arrangements are made for the recording of medication for residents. This refers specifically to omissions on the MAR record. Ensure that all care staff/senior staff receive appropriate training pertaining to challenging behaviour and protection of vulnerable adults. Ensure that robust recruitment procedures are adopted and that all records as required by regulation are sought. Ensure that all staff receive appropriate training to the work they perform. This refers to gaps in individuals training and training specifically relating to the needs of older people. Ensure that all staff working at the care home receive appropriate training for the safe system for moving and handling DS0000065444.V338928.R01.S.doc Timescale for action 14/07/07 2. OP9 13(2) 14/07/07 3. OP18 13(6) 01/10/07 4. OP29 19, Schedule 4 18(1)(c) and(i) 14/07/07 5. OP30 01/10/07 6. OP30 13(5) 01/08/07 Grays Court Version 5.2 Page 25 7. OP36 18(2) residents. Ensure that all staff are regularly supervised. 14/07/07 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 OP7 OP15 OP16 Good Practice Recommendations Ensure that daily care records are detailed, informative and reflect how residents spend their day. Implement a pictorial menu for residents and consider and devise ways of enabling those residents with dementia to make an informed choice from the menu. Ensure that the complaints procedure is amended to reflect that CSCI no longer has any statutory requirement to investigate complaints. Grays Court DS0000065444.V338928.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Grays Court DS0000065444.V338928.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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