Inspection on 10/10/05 for Priestley Care Home

This inspection was carried out on 10th October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Priestley Care Home 16/05/07

Priestley Care Home 18/05/06

Priestley Care Home 18/05/05

Priestley Care Home 03/02/05

Priestley Care Home 02/08/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Priestley Care Home Market Street Birstall West Yorkshire WF17 9EN Lead Inspector John Gregory Unannounced Inspection 10th October 2005 08:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Priestley Care Home DS0000029924.V255557.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. Priestley Care Home DS0000029924.V255557.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Priestley Care Home Address Market Street Birstall West Yorkshire WF17 9EN 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) 01924 440266 01924 440268 Tri-Care Limited Mrs Diane Julie Waite Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Priestley Care Home DS0000029924.V255557.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th May 2005 Brief Description of the Service: Priestley Care Home provides accommodation and personal care for up to 40 older people. It is owned by Tri-Care Ltd, a company, which has a small number of care, homes in the area. The home is situated in the centre of Birstall, close to local shops and amenities. The home was purpose built and registered almost three years ago. Accommodation is provided over two floors and there is a passenger lift. Both floors have a lounge and dining area and all bedrooms have en-suite facilities. There is a garden on two sides of the home, to which residents have access. There is adequate car parking at the front of the building. Priestley Care Home DS0000029924.V255557.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over the course of one day in October. The inspection focused on assessment of the standards that the CSCI determine are central to the care process. A number of policies procedures and records were examined that were relevant to the standards inspected. The files of six service users were examined, three of which were examined in close detail. Interviews were held in private with five service users and two relatives. Six staffing files were examined and individual interviews were held in private with five staff. A brief tour of the building was undertaken. The home’s manager assisted the inspector with the inspection fieldwork. The inspector would like to thank the service users, staff and manager of Priestley care home for their time, cooperation and hospitality on this inspection. What the service does well: What has improved since the last inspection? The manager and service provider are to be commended on the effective action taken to deal with the high level of statutory requirements and recommendations from previous inspections. Priestley Care Home DS0000029924.V255557.R01.S.doc Version 5.0 Page 6 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. Priestley Care Home DS0000029924.V255557.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 Priestley Care Home DS0000029924.V255557.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): 3 The service users are admitted on the basis of an assessment that ensures that their needs can be met within the home. EVIDENCE: All the files examined contained either a full pre-admission assessment undertaken by the home’s manager or on an assessment made under the care management arrangements. Service users could not recollect this process but recollected their family visiting the home to inform their decision about becoming resident. All the service users confirmed that their needs were being met. Priestley Care Home DS0000029924.V255557.R01.S.doc Version 5.0 Page 9 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 The service users care is underpinned by basically good care plans which need to become more consistent .The health care provided is good and the medication procedures protect service users. The service users’ care in the home protects their privacy and dignity. EVIDENCE: The care plans examined contained a full list of areas relevant to the service user’s life and relevant risk assessments. However, some of the plans were not completed with the same high degree of information as others. Reviews by care staff were completed monthly to keep the care plan relevant to service users’ care. Service users confirmed that they had discussion with care staff about their needs. Service users confirmed good access to medical service through the primary health care team, the detail of which was contained on file. The service provider’s medication procedure would benefit from development along the lines outlined within the Royal Pharmaceutical Guidance for Care Priestley Care Home DS0000029924.V255557.R01.S.doc Version 5.0 Page 10 Homes. The medication of four service users was audited and found to be accurate. The service users’ care was observed to be based on life in their individual rooms, transactions by staff were observed to be positive. Service users were all well dressed in their own clothing, and some have telephones in their own rooms. Priestley Care Home DS0000029924.V255557.R01.S.doc Version 5.0 Page 11 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 Service users are able to choose from a variety of lifestyles from the activities on offer. There is the availability of unlimited contact from family and friends who have the facility to enjoy hospitality within the home. Service users have a wide variety of choice available to them in their day-today care and receive a good wholesome diet. EVIDENCE: The service users confirmed that they have access to a wide range of stimulating activities in the home should they wish to become involved. This includes trips out to local areas of interest. Some service users were happy to spend time in their own rooms on their own choice of activity. Relatives confirmed that they feel able to visit the home at any time and are able to enjoy hospitality within the home. Service users confirmed that they have a choice of lifestyles based on their own rooms, have a choice of activities, meals and a good level of personalisation within the home. The diet is based on a two weekly menu which offers choice at all meals of wholesome meals, which can be taken in their own rooms or in the communal Priestley Care Home DS0000029924.V255557.R01.S.doc Version 5.0 Page 12 dining areas. Service users were unanimous in their appreciation of the food on offer. Priestley Care Home DS0000029924.V255557.R01.S.doc Version 5.0 Page 13 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 & 18 The service provider has a complaints procedure in which the service users have confidence. The policies, procedures and practice within the home protect service users from abuse. EVIDENCE: The service provider has a complaints procedure which is well circulated, is understood by staff and in which the service users expressed confidence. There have been no complaints received in the home since the last inspection. Staff understand the policy and procedures for the prevention of abuse to adults and whistle blowing. All staff have recently had training on issues of abuse and would act confidently should the need arise. Priestley Care Home DS0000029924.V255557.R01.S.doc Version 5.0 Page 14 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 & 26 The service users live in a safe, well-maintained environment to which only minor attention is needed. The accommodation was clean, tidy and furnished in a domestic manner. EVIDENCE: A brief tour of the building identified the home to be basically safe and well maintained, clean, tidy and hygienic except for the area outside the kitchen where the carpet is heavily stained and needs deep cleaning or replacing. Not all the access points from the home are such that they could be safely negotiated by a wheel chair. The laundry is clean with commercial equipment and impervious walls and ceiling. Cleanliness would be further enhanced by the appointment of designated laundry staff. Priestley Care Home DS0000029924.V255557.R01.S.doc Version 5.0 Page 15 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, 29, & 30 The staffing level is currently sufficient to meet the basic needs of service users although the level of staff turnover remains high. The recruitment practices protect service users. The staff are committed well trained. EVIDENCE: The staffing level is based on five staff being on duty during the day and three waking night staff. Due to a reduction of dependency levels in the home and virtually no use of agency staff, this is adequate for the basic care of service users. The staff turnover remains high, with one third of the staff changing every six months, a matter which needs some examination. The hygiene within the home and the pressure on staff would be reduced by the appointment of specialist laundry staff. The recruitment process is thorough and protects service users. The staff are well trained and feel that they have the skills to do the job. Staff are held in high regard by the service users for their hard work and helpfulness. Priestley Care Home DS0000029924.V255557.R01.S.doc Version 5.0 Page 16 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): 33,35 & 38 The service provider has begun to develop policies and procedures which will ensure that the home is run in the best interests of service users. The formal oversight of the home’s functioning needs to be increased. The service users’ financial interests are safeguarded. The policy, procedure and practice on health and safety basically protects service users; minor attention is necessary. EVIDENCE: The service provider has developed a process of internal auditing and questionnaires for staff and service users, which have not yet been correlated. This does not yet amount to a full quality assurance system. This matter should be more closely examined at the next inspection. Records of visits to the home on behalf of the responsible body are not up to date and should be increased to demonstrate proper support and supervision of the home. Priestley Care Home DS0000029924.V255557.R01.S.doc Version 5.0 Page 17 Records of the day-to-day expenditure of service users made by the home were examined and found to balance with appropriate use of receipts. The service provider undertakes regular workplace risk assessments and rectifies any faults. Service users and staff feel safe living and working in the home. Fire risk assessments, fire tests and drills are routinely undertaken but were out of date in terms of the recording. COSHH records were complete. Health and hygiene tests in the kitchen were up to date. Priestley Care Home DS0000029924.V255557.R01.S.doc Version 5.0 Page 18 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 X 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 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X 3 X X 1 Priestley Care Home DS0000029924.V255557.R01.S.doc Version 5.0 Page 19 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 Op 33 Regulation 26 Requirement Timescale for action 01/12/05 2 Op 38 17 Schedule 4 (14) The service provider must arrange for the home to be visited monthly and a report prepared in line with the regulations. Former timescale 01/06/05 The service provider must keep a 01/12/05 record of every fire practice, drill or test of fire equipment conducted in the care home and of any action taken to remedy defects of the fire equipment 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 OP27 OP 7 Good Practice Recommendations The service provider should ensure that care staff are not taken from care duties in order to undertake work in the laundry. The service users care plans should be completed more consistently and with a greater level of detail. DS0000029924.V255557.R01.S.doc Version 5.0 Page 20 Priestley Care Home 3 4 5 Op 9 Op 19 OP 27 The medication procedure should be developed to include all areas recommended in the royal Pharmaceutical guidance for care homes. The carpet in the corridor outside the kitchen should be thoroughly cleaned or replaced. The service provider should develop an action plan to reduce the level of staff turnover. Priestley Care Home DS0000029924.V255557.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Priestley Care Home DS0000029924.V255557.R01.S.doc Version 5.0 Page 22 - 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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