Inspection on 18/05/05 for Priestley Care Home

This inspection was carried out on 18th May 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 10/10/05

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 Jim Leyland Bronwynn Bennett Unannounced 18 May 2005 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 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 J51J01_s29924_Priestley Care Home_v220864_180505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Priestley Care Home Address Market Street Birstall West Yorkshire WF17 9EN 01924 440266 01924 440268 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Tri-Care Limited Care home 40 Category(ies) of 40 x Old age (over 65 years) registration, with number of places Priestley Care Home J51J01_s29924_Priestley Care Home_v220864_180505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 3 February 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 haver 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 J51J01_s29924_Priestley Care Home_v220864_180505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors arrived at Priestley at 1pm to carry out an unannounced inspection and left at 6pm. Thirteen of the residents, four members of staff and the manager and deputy manager were spoken to. A sample of records, including care plans, policies and procedures, staff recruitment and training records were examined. A visit was also done in March to follow up previous requirements and recommendations. There have been a number of improvements, however concerns remain about recruitment practice, staff cover, staff induction, quality assurance and health and safety. Thank you residents, staff and manager for your assistance and input to this inspection. What the service does well: What has improved since the last inspection? What they could do better: The service provider must recommence monthly visits to the home to monitor care practice. Recruitment practice in the home must improve in order to Priestley Care Home J51J01_s29924_Priestley Care Home_v220864_180505.doc Version 1.30 Page 6 protect residents. The views of people living the home and their families need to be considered to meet the aims and objectives of the home. Action is required to ensure that staff can meet the needs of residents, considering dedicated staff for the laundry and ensuring that staff and managers are not working excessive hours. New staff must be trained appropriately in order to be competent to carry out their role. People living in the home need to be safeguarded by making sure that substances hazardous to health, for example cleaning products, are stored securely. 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 J51J01_s29924_Priestley Care Home_v220864_180505.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Priestley Care Home J51J01_s29924_Priestley Care Home_v220864_180505.doc Version 1.30 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 standard(s) 3 The needs of residents are assessed by persons qualified to do so and by the manager of the home, prior to admission. The manager is able to say whether or not the prospective placement is appropriate. EVIDENCE: The files of two residents were checked; both included a community care assessment, which had been completed by a social worker and a preadmission assessment form completed by the manager. Where privately funded service users are admitted, the manager uses a comprehensive assessment, which covers the elements set out in the standard. A visiting social worker commented that the manager of the home informs the Care Management Team about whether or not the home is able to meet the individual’s needs. This is an improvement since the previous inspection, when some residents had been inappropriately placed. The social worker said that a family had informed her that staff had been tolerant when working with a resident who has mental health problems. Priestley Care Home J51J01_s29924_Priestley Care Home_v220864_180505.doc Version 1.30 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 standard(s) 7, 8, 9 and 10 The care needs of residents are set out in individual plans; some improvements could be made in terms of reviewing the plans and involving residents and their families. Residents have access to appropriate health care support. The medication system has improved; there are some minor discrepancies in the recording. Following an incident at the inspection, staff need to more mindful in promoting dignity and respect for residents who require assistance. EVIDENCE: Four residents’ care plans were examined during the inspection visit. Personal support plans have been devised setting out the preferences, likes and dislikes of residents. Each individual need is noted and any actions required by staff to support the person. Plans include life histories and information about social background. Appropriate risk assessments have been completed, for example explaining why one resident had chosen not to have footplates on their wheelchair. The manager explained that care plans are being devised and consultation is taking place with the new area manager. Three recommendations are made regarding care plans. Firstly each resident should have their own care plan file, Priestley Care Home J51J01_s29924_Priestley Care Home_v220864_180505.doc Version 1.30 Page 10 incorporating information about them in one place, in order to promote personcentred recording and Data Protection. Secondly whilst a general review of the personal support plans is taking place, it is recommended that each need is reviewed so that staff monitor the well being of a service user in a more holistic way. Thirdly a recommendation is made that evidence of resident and family involvement is provided, when devising and reviewing care plans. Evidence in care plans shows that residents have access to primary health care, including GPs, district nurses and the Continuing Care Team. In the daily records of one service user, detailed information about the changes in the mental health of a service user was noted and the GP contact sheet evidenced that these concerns were followed up promptly, to provide the appropriate outcome for the resident concerned. Residents said that they had access to dentists, opticians and chiropodists. The manager has purchased new weighing scales, however a recommendation is made as four care plans seen showed that the residents’ weight had not been recorded for six months. Appropriate advice and support is sought about tissue viability from district nurses and some residents have been assessed as needing suitable pressure care relieving equipment. One resident had signed a contract to say that they would self-administer medication and had agreed to audits by staff. Two residents’ medication was checked. One of the residents’ medication administration records had some minor discrepancies in terms of stocks not balancing. It is recommended that closer auditing be undertaken by the manager to monitor recording. Previous requirements and recommendations relating to controlled drugs and use of appropriate codes have now been addressed. One example of good practice includes information on MAR sheets advising staff about how and where medication is administered for each individual. Residents said that staff help them with personal care needs in a respectful way; one commented that their privacy was respected as they chose to spend most of the day in their own room. However a requirement is made following an incident that took place during the inspection visit. One resident was distressed and used the on call buzzer for assistance. No staff were available and the individual waited over 10 minutes for staff to respond, relying on the inspectors to come and find them. The dignity of service users must be maintained at all times. The manager explained that families and key workers support residents to purchase new clothes. Residents receive their mail unopened and there is a public telephone line for residents’ use. Priestley Care Home J51J01_s29924_Priestley Care Home_v220864_180505.doc Version 1.30 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 standard(s) 12 Residents at Priestley are able to participate in appropriate activities, based on consideration of their interests and preferences. EVIDENCE: Service users said that they are able to get up and go to bed at times of their choosing. This information is written in the personal support plan, following consultation with the resident and/or their family at the point of admission. The plans also include information about their social history and spiritual needs. A notice in the reception area stated that a religious service takes place in the home one Sunday per month. An activities schedule is available and residents confirmed that entertainers had visited and manicures, bingo and skittles have taken place. One resident said that they preferred to spend time in their own room and that staff respected this. On the day of the inspection residents were involved in various activities for example: board games, singing to old time songs and playing dominoes with staff. Several residents huddled around the television to watch their favourite television programme and staff supported them to put on the subtitles. Priestley Care Home J51J01_s29924_Priestley Care Home_v220864_180505.doc Version 1.30 Page 12 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 standard(s) 16 and 18 Residents are confident that if they made a complaint or expressed a concern that they would be listened to and action taken to resolve the matter. Residents are protected from abuse through appropriate procedures and staff training. EVIDENCE: There is a detailed complaints’ procedure for the home and service user’s said that they felt able to approach staff and raise any concerns or make a complaint. No complaints have been received since the last inspection. The manager said that following a previous recommendation, the service provider would inform the complainant about the outcome of their complaint and details about their rights for redress and appeal. Two staff said that they had recently completed training on Adult Protection. The manager provided written evidence that all staff have completed the workbooks on Adult Abuse Training, verified by them. This covers information about whistle blowing, recognising abuse and dealing with an allegation. The service provider has a policy and procedure for the prevention of abuse and a copy of the Kirklees joint agency procedure in the home. Priestley Care Home J51J01_s29924_Priestley Care Home_v220864_180505.doc Version 1.30 Page 13 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 standard(s) 19 Residents in the home live in a comfortable and well-maintained environment, which is adapted for their safety. EVIDENCE: The home was purpose built three years ago and there has been little need for maintenance. The manager explained that any repairs are logged with the maintenance department and dealt with on a priority basis. A recent Environmental Health report stated recommendations relating to manual handling for inanimate objects and storage of foodstuffs, which have now been addressed. A response has been received from Tri-Care with an action plan for remedial works to address outstanding recommendations from West Yorkshire Fire Service. The manager explained that training was due to take place for staff, relating to mattress assisted evacuation of residents from the first floor and the maintenance department confirmed that the fire alarm system is of the appropriate standard. Priestley Care Home J51J01_s29924_Priestley Care Home_v220864_180505.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Some staff have worked excessive hours and were not always available to meet the needs of residents. Recruitment practises in the home must be improved to safeguard residents. The induction for staff needs to be more detailed and meet relevant standards. EVIDENCE: The duty rota showed that the minimum number of staff are available on each shift for the number of residents in the home. However on the day of the inspection the needs of one resident were compromised, due to no staff being available. The minimum number of staff used is four during the day and three after 5pm and overnight, with three waking night staff. The manager and deputy manager have been working excessive hours in order to meet the shortfall on the rota, covering vacancies. This comprises their ability to undertake their duties effectively and safely. Agency staff are being used and progress has been made in getting shifts covered, with the manager trying to use the same staff, to provide consistency for residents. It is recommended that the manager commence an induction pack for agency staff. Domestic staff have now been appointed and there are dedicated kitchen staff in the home A recommendation is made that a member of staff coordinates the laundry tasks, in order to promote an efficient service, appropriate levels of hygiene and reduce items of clothing from going missing. Priestley Care Home J51J01_s29924_Priestley Care Home_v220864_180505.doc Version 1.30 Page 15 Following previous requirements, concerns remain about recruitment practice at the home. One staff file examined had no explanation for several years’ gap in their employment. One staff file had no confirmation of a satisfactory enhanced Criminal Records Bureau disclosure being received. They had also commenced work in the home without being checked on the Protection of Vulnerable Adults list. One staff file contained only one written reference. These recruitment practises are unacceptable and must be tackled, in order to safeguard residents living at Priestley. Improvements to the induction of staff is needed. The current induction lacks detail and is not to TOPSS standards. The manager pointed out that she has acquired the TOPSS workbooks, but has had no time to implement this training to new staff. New staff do work under supervision from more experienced members of staff. Evidence was seen that progress is being made in relation to basic training for staff being commenced. Three members of staff confirmed that they had undertaken moving and handling training, food hygiene, adult abuse training and basic first aid. Priestley Care Home J51J01_s29924_Priestley Care Home_v220864_180505.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 36 and 38 Effective quality assurance is not being undertaken in the home and the views of residents must be gauged to ensure that the home is run in their best interests. Improvements have been made to auditing residents’ finances. Staff receive regular supervision and annual appraisals have commenced. Substances hazardous to health must be stored appropriately and safely. EVIDENCE: The manager confirmed that there had been no progress with devising and implementing an effective quality assurance tool at Priestley. The views of residents, their relatives and other stakeholders must be sought about the home and used to provide outcomes for residents. The last evidence of a statutory visit to the home by the service provider was in September 2004. A requirement was made at the previous inspection that visits are made monthly. These visits must recommence to provide effective auditing and support for the staff and manager at the home. Priestley Care Home J51J01_s29924_Priestley Care Home_v220864_180505.doc Version 1.30 Page 17 The manager explained that if a resident required support to manage their financial affairs, then referrals to advocates or legal services would be made. An advocate supports one resident to help manage their money. Receipts are now kept of all transactions and these are kept for individual residents. The money of two residents was checked and one had a minor discrepancy between the balance and the information recorded on the transaction record. A recommendation is made that closer auditing of residents’ finances is undertaken in order to trace any errors. Staff confirmed that since the appointment of the new manager that regular supervision is now taking place. Records were checked and confirmed that most of the staff team have received supervision in the last 2 months. Annual appraisals have now commenced for staff to identify training and development needs. One requirement is made in relation to health and safety. On the day of the inspection, the laundry door was left unlocked, giving access to substances hazardous to health. This must be addressed and monitored to safeguard residents. Priestley Care Home J51J01_s29924_Priestley Care Home_v220864_180505.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 1 28 x 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 1 x 2 3 x 1 Priestley Care Home J51J01_s29924_Priestley Care Home_v220864_180505.doc Version 1.30 Page 19 yes 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. 1. Standard 10 Regulation 12(4)(a) Requirement The registered person must make arrangements to ensure that the care home is conducted in a manner that respects the privacy and dignity of service users. The registered person must ensure that at all times suitably qualified, competent and experienced persons are working at the care home in numbers appropriate for the health and welfare of service users. The registered person must ensure that staff files include all the relevant information specified in Schedule 2: Staff must not be employed without an enhanced CRB disclosure, full and satisfactory informatoion from the POVA register and two written references. The registered person must provide work appropriate training through structured induction training. The service provider must establish a quality assurance system in order to improve the quality of care for residents in Timescale for action 30th June 2005 2. 27 18 28th March 2005 3. 29 19 Schedule 2 28th March 2005 4. 30 18 31st July 2005 28th March 2005 5. 33 24(1) Priestley Care Home J51J01_s29924_Priestley Care Home_v220864_180505.doc Version 1.30 Page 20 the home. 6. 33 26 The service provider must ensure that visits on its behalf are made with the frequency and in the form specified in the regulations. The registered person must ensure that all parts of the home to which service users have access are free from hazards to their safety: Substances hazardous to health must be stored securely and safely. 28th March 2005 7. 38 13(4)(a) 30th June 2005 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 7 Good Practice Recommendations Each resident should have their own care plan file, incorporating information about them in one place, in order to promote person-centred recording and Data Protection. It is recommended that each need in care plans is reviewed so that staff monitor the well being of a service user in a more holistic way. A recommendation is made that evidence of resident and family involvement is provided, when devising and reviewing care plans. It is recommended that closer auditing be undertaken by the manager to monitor recording of medication. The service provider should ensure that care staff are not taken from care duties in order to undertake work in the laundry. It is recommended that agency staff receive a basic induction when working in the home. There should be closer auditing of service users financial records, in order to account for any errors. 2. 3. 4. 5. 6. 7. 7 7 9 27 30 35 Priestley Care Home J51J01_s29924_Priestley Care Home_v220864_180505.doc Version 1.30 Page 21 Commission for Social Care Inspection 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 J51J01_s29924_Priestley Care Home_v220864_180505.doc Version 1.30 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. 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!