Inspection on 13/12/05 for 5 Priory Drive

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 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 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

5 Priory Drive 01/03/07

5 Priory Drive 08/06/05

5 Priory Drive 09/12/04

5 Priory Drive 20/07/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 5 Priory Drive 5 Priory Drive Totnes Devon TQ9 5HU Lead Inspector Graham Thomas Unannounced Inspection 10:00 13 December 2005 th 5 Priory Drive DS0000003633.V249785.R01.S.doc Version 5.0 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 5 Priory Drive DS0000003633.V249785.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 Adults 18-65. 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. 5 Priory Drive DS0000003633.V249785.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 5 Priory Drive Address 5 Priory Drive Totnes Devon TQ9 5HU 01803 867554 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) Katherine H L Finnigan The Very Rev Archpriest Benedict Ramsden, Mr Simeon Ramsden, Mrs Lilah Ramsden Miss Tamsin Jane Pope Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places 5 Priory Drive DS0000003633.V249785.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2005 Brief Description of the Service: 5 Priory Drive is a small residential home, set close to the centre of Totnes, providing care for up to three service users with mental healthy needs. The home is one of a number operated by the Community of St Anthony and St Elias, a partnership providing care in small domestic settings in the Totnes or Plymouth areas. For ease of reference The Community of St. Anthony and St. Elias will be referred to as “the Community” throughout this report.The home is a domestic property, adjacent to two other properties owned by the Community. Three bedrooms are provided for service users, with bathroom and toilet facilities, a kitchen, a conservatory/dining room and a small lounge. There is an attractive small garden and limited parking. Service users have access to the services of the Community such as an extensive outdoor activities programme, arts and crafts activities and work placements. Since the last inspection a new manager has been registered. 5 Priory Drive DS0000003633.V249785.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During the inspection, all three service users were seen. The inspector spoke with one privately and two more generally. A range of issues was discussed with the Registered Manager. Samples of the home’s records were examined including care plans and other documents. What the service does well: What has improved since the last inspection? 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. 5 Priory Drive DS0000003633.V249785.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 5 Priory Drive DS0000003633.V249785.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Prospective service users have adequate information upon which to base their choice of home. They can feel confident that their identified needs will be met by the home. EVIDENCE: A Statement of Purpose and Service Users Guide have been produced. These take the form of brochures with inserts, which provide detailed information. At the last inspection, the inserts were found to be missing. This has now been rectified and complete information is available to service users and others. The Inspector spoke with a recently admitted service user and examined the care plan file. The service user had been visited by Community staff and opportunities had been given to stay at Priory Drive prior to admission. Preadmission assessments had been completed by the Community. These included gathering information from the referring agencies. On the day of inspection, service users were being supported by a mix of experienced and more recently recruited staff. Induction training is in place which provides staff with specific knowledge and skills relating to the needs of this group of service users. Interactions observed between staff and service users were relaxed, respectful and supportive. Discussion with staff, service users and evidence from records showed that individual needs had been clearly identified and were being met with the help of external professionals where required. A new daily recording system was being piloted at the time of inspection. This had emerged from the Community’s quality assurance process and aims to link daily recording more closely to specific needs identified in individual care plans. 5 Priory Drive DS0000003633.V249785.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the above standards was inspected on this occasion 5 Priory Drive DS0000003633.V249785.R01.S.doc Version 5.0 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 Service users are well supported to maintain a wholesome, nutritious and enjoyable diet. EVIDENCE: Menus were examined and these were discussed with the Registered Manager. Each service user has the opportunity to choose his/her preferred meals. Shopping for food on a daily basis forms part of the home’s routine and enables service users to plan and participate in meal preparation. Service users and their records confirmed that individual needs are catered for. The menus showed a varied and wholesome diet. Meal plans are kept and there is space on these forms for review and monitoring by the Registered Manager. Since the last inspection recording in this area has improved and there are now detailed observations and review of the menus. Care plans identified individual dietary needs and preferences which were reflected in the menus. 5 Priory Drive DS0000003633.V249785.R01.S.doc Version 5.0 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The safety and welfare of service users are protected by adequately rigorous systems of recording the use of medicines. EVIDENCE: Since the last inspection, service users’ safety has been enhanced by improvements in the recording of the administration of medicines. At the time of the inspection, no controlled drugs were in use. However, the Registered Manager demonstrated her awareness of the storage and recording requirements should the need arise. Since the last inspection, a system has been introduced which shows clearly the numbers of remaining tablets where a monitored dosage system is not used. Records concerning the administration of medicines were sampled and found to be up to date and in good order. Some “as required” (PRN) medication is administered. Staff were clear as to the circumstances under which these medicines might be administered though there are presently no written guidelines. 5 Priory Drive DS0000003633.V249785.R01.S.doc Version 5.0 Page 11 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the above standards was inspected on this occasion 5 Priory Drive DS0000003633.V249785.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the above standards was inspected on this occasion 5 Priory Drive DS0000003633.V249785.R01.S.doc Version 5.0 Page 13 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 34 Service users are supported by a staff group with a relevant mix of skills and experience. The recruitment of staff is adequately rigorous to protect service users from potential abuse. EVIDENCE: The staff group at 5 Priory Drive includes some very experienced workers. This has been confirmed both from records and observations during inspection visits. There is a detailed and comprehensive induction training programme for all staff. However, due to recent staff turnover, the numbers of staff qualified specifically in care has fallen and is unlikely to meet national targets set for the end of 2005. Some staff, however, hold higher level qualifications in subjects relevant to their work (e.g. Psychology). NVQ training is made available by the Community. Individual staff training files have been seen which show training specific to service users’ needs. Occasional short courses are also available for updating specific skills / knowledge in, for example, first aid. Interactions between staff and service users during the inspection demonstrated a respectful and thoughtful approach to meeting service users’ needs. This was also reflected in the records sampled, which demonstrated a detailed awareness of individual need. Discussion with recently recruited staff and the Registered Manager confirmed a rigorous recruitment policy. This includes visiting the home, application, interview, the provision of two references and criminal records checks. One worker from the Czech Republic confirmed that she had provided a Czech 5 Priory Drive DS0000003633.V249785.R01.S.doc Version 5.0 Page 14 police check as well as undergoing a UK criminal records check. Staff receive statements of terms and conditions and new recruits are subject to a probationary period of employment. 5 Priory Drive DS0000003633.V249785.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 Service users benefit from living in a home well-run by a competent manager. EVIDENCE: Records, observation, and discussion with service users confirm that the Registered Manager has run the home competently and effectively since her appointment. Service users feel that their voice is heard, that their needs and aspirations are met and that they are well supported. The inspection confirmed that she has worked effectively towards compliance with requirements and recommendations made on previous visits. In discussion she demonstrated a clear understanding of her responsibilities which is reinforced by the successful completion of the Registered Managers Award and NVQ level 4 in Care. 5 Priory Drive DS0000003633.V249785.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X 3 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 5 Priory Drive Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X X X DS0000003633.V249785.R01.S.doc Version 5.0 Page 17 No Are there any outstanding requirements from the last inspection? 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA20 Good Practice Recommendations Written guidance should be provided for staff giving specific details of the circumstances in which “as required” (PRN) medication is to be administered to individuals for whom it is prescribed. 5 Priory Drive DS0000003633.V249785.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 5 Priory Drive DS0000003633.V249785.R01.S.doc Version 5.0 Page 19 - 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!