Inspection on 23/01/08 for Primecare Nursing Home

This inspection was carried out on 23rd January 2008.

CSCI found this care home to be providing an Good service.

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

Primecare Nursing Home 16/02/10

Primecare Nursing Home 15/02/07

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Primecare Nursing Home 62 Downs Grove Vange Basildon Essex SS16 4QL Lead Inspector Trevor Davey Unannounced Inspection 23rd January 2008 10:20 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 Primecare Nursing Home DS0000068042.V358374.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. Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Primecare Nursing Home Address 62 Downs Grove Vange Basildon Essex SS16 4QL 01384 70275 01384 79658 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) Choicecare 2000 Ltd Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 2007 Brief Description of the Service: Primecare is a purpose built care home and is registered to provide personal and nursing care with accommodation for 42 people over 65 years of age. Accommodation is provided over two floor levels and a shaft lift is available to give access to all areas. The accommodation is comprised of thirty-four single and four shared bedrooms. Ensuite facilities have been provided in eight of the bedrooms. There are two large communal lounge areas, one on each floor and the dining room is situated on the ground floor. People living at the home have access to a patio and garden which is accessible to people who use wheelchairs. The grounds include well maintained gardens and good car parking facilities. The home is within easy reach of Basildon town centre, public transport services and local amenities. The current rate of fees range from £434.60 to £625.00 per week. Additional charges are made for hairdressing, chiropody, toiletries and newspapers. Information about the home is made available to prospective residents in the Statement of Purpose and Service User’s Guide. Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use the service experience good quality outcomes. The Key Inspection site visit covered a period of 8.50 hours and covered all key standards. The manager together with staff, residents and other health care professionals were available during the site visit and were spoken with. Their comments and contributions received were helpful in assisting the Inspector to prepare the report. As part of the site visit, a tour of the premises took place. Personal care records and other official records within the home were inspected. The information included in the annual quality assurance assessment form (AQAA) which had been submitted to the Commission for Social Care Inspection, was also used in compiling the inspection report. This form gives homes the opportunity of recording what they do well, what they could do better, what has improved as well as future plans for improving the service. Feedback from survey information, was also taken into account. Matters relating to the outcome of this inspection were discussed with the manager. Full opportunity was given for discussion and/or clarification both during and at the end of the site visit. What the service does well: The management are committed to promoting high quality care and ongoing improvements have taken place in the home since the last inspection. Residents and their relatives have been encouraged to express their views in meetings, which are arranged as well as completing survey questionnaires. Overall, comments made to the Inspector by residents were positive and expressed satisfaction that personal choice, daily routines and individual wishes were being respected. Comments made by health care professionals confirmed that a good working relationship existed with the home and the training provided for staff appeared to be appropriate in order to provide them with the skills necessary to meet the personal care and nursing needs of residents. Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 6 An imaginative social activities programme is in place, which gives residents options to be involved as they choose and this has also provided good opportunities for reminiscence and social stimulation. Residents also spoke of how they enjoyed some of the recreational and craft activities. This included residents who had been given opportunities to enjoy new leisure experiences for the first time. Resident’s comments were positive regarding the welcome received on arrival at the home and how the staff were friendly as well as providing good personal care and support. Staff were observed to be sensitive in their communication with residents as well as using their skills to provide appropriate support and nursing care. Responses received from health care professionals by the Commission for Social Care Inspection, included positive comments to say that the home is good at providing holistic care as well as good emotional support for the mental well-being of residents. A detailed recording system covering recruitment checks and procedures was available. Information was recorded to show how induction of new staff had taken place as well as ongoing training courses attended by the staff team. The environment of the home was clean, comfortable with infection control and hygiene standards being maintained. Reports were available for inspection of regular monitoring and monthly visits which had taken place on behalf of the registered provider to ensure policies, practices and procedures had been maintained in the home. What has improved since the last inspection? Since the last inspection, the majority of requirements and recommendations identified in the previous report have been addressed or are in the process of being met. These include a thorough and detailed assessment of nursing care needs prior to admission, and staffing levels have been reviewed. Considerable improvements have been made in the provision and variety of activities to increase social stimulation. This takes into account the needs of individuals as well as the organisation of group activities. In their selfassessment (AQAA) form, the home state that they have used the suggestions made by residents at their meetings, to make changes to the activities provided in the home. Individual records for residents are maintained showing social and other recreational activity where individuals have been involved. Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 7 Improvements have also been made in the information recorded within personal care plans and this process is ongoing. Menus have been changed to take account of requests made by residents to give a greater variety and choice. Since the last inspection, new laundry equipment has been provided, redecoration has taken place in the main dining room as well as 50 of the bedrooms and the kitchen floor has been renewed. Other furnishings and equipment have also been renewed. Staff have received training in respect of reporting procedures related to safeguarding adults from harm. 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. Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 8 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 Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 9 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 (standard 6 is not applicable in this home) People who use the service experience excellent quality outcomes in this area. Residents can expect to have their care and nursing needs assessed by the home to ensure that the proposed placement is suitable. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A sample check was made of pre- admission information, which was available for two residents one of whom, was visiting the home for the first time. There Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 10 is normally a six-week assessment period and information had been provided to the home by the Primary Care Trust, that included an overview of medication, blood pressure, mobility, mental health and occupational therapist assessments as well as a statement from the relative. The Inspector spoke with this prospective resident who commented that they were made to feel very welcome in the home and that they had really enjoyed their dinner. The home assessment co-ordinator from the hospital was also spoken with who had been involved with the pre-admission assessment. Positive comments were made to the Inspector confirming that there was good communication with the management and that a professional relationship existed with the home. A pre-admission assessment form had also been completed by the home, which included past medical history, current personal circumstances, details of personal and dental care as well as dietary needs. Medication administrative record sheets had also been received from the hospital. Other information, which had been recorded and taken into account, included dietary needs, leisure and hobbies and a self-care checklist. A section had also been included for any specific nursing needs. Details of named staff were included and an initial moving and handling risk assessment was on file. Photographs of residents to clarify identification are also included with these personal care records. Similar information was available for other residents who had been recently admitted to the home, which included records of the managements Hospital assessment. The pre-admission arrangements takes into account short-term visits to the home when lunch is also provided. A copy of the Statement of Purpose and Service User’s Guide were available in the entrance hall and copies had been given to residents. One of the residents showed the Inspector their copy of the Service User’s Guide, which was in their bedroom. The home does not provide intermediate care. Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 11 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 People who use the service experience good quality outcomes in this area. Residents can expect to have a plan of care drawn up by the home that details all there assessed needs and the management of risk and can expect to receive the services of health care professions. Residents can expect the home to manage the administration of medication in accordance with accepted good practice guidelines. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 12 A selection of personal care records were available for inspection, which included care plans and risk assessments. Individual care plans had been completed that included mobility, climbing stairs, washing and dressing. Risk assessments had also been completed where required and included the use of bed rails and the safe use of hoisting equipment. Care plans were drawn up to include the identified problem, expected outcome, plan of care/support as well as the date of the next evaluation. From the samples inspected, regular reviews had taken place. The registered manager prepares reports on all aspects of personal nursing care which includes medication and the conclusions reached. The home recognises the need to continue the updating process to ensure all care plans are personalised and reflect how specific individual needs are to be met. Records were available to show the intervention and treatment provided by other health care professionals. Feedback from questionnaires completed by health care professionals for the Commission for Social Care Inspection, confirmed that the home seeks advice and acts upon this to improve the health and care needs of individuals. They also considered the staff of the home to have the right skills and experience to support individual’s social and health care needs. Some of the residents spoken with said that staff were excellent and responded quickly when assistance was required. Residents were also reassured that staff regularly checked on their well-being at night. Staff were observed to be knowledgeable, sensitive and interacted well with residents when providing care and support. Staff were seen to be patient and able to demonstrate that they could converse appropriately with residents who had communication problems or sensory impairments. Some of the residents spoken with who had been in the home for some time, said the staff were good and responded well to meeting their personal care needs. A check was made of the medication administrative arrangements in the home with one of the nurses from the staff team. From the sample checks made, the medication administrative records (M.A.R.) were being completed in accordance with agreed procedures. Entries and signatures corresponded with prescription instructions and drugs had been properly accounted for. Details had been recorded when new medication had been received into the home and records were available of discontinued drugs, which had been returned to the pharmacist. Protocols had been completed for P.R.N. (to be taken as required) medication. Local doctors had confirmed changes to medication and the pharmacist also undertakes a monthly audit of medication. The controlled drugs register had been properly maintained with correct entries and two staff signatures. All medication is audited every twelve hours and staff signatures had been provided to confirm that this had taken place. A comment included in a questionnaire submitted by a health care professional, felt that the home needed to address some issues regarding prescription dispensing with the local pharmacist. Primecare Nursing Home DS0000068042.V358374.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 People who use the service experience excellent quality outcomes and this area. Residents can expect to receive a balanced diet and assisted in maintaining family/friend/community contact. Residents can always be assured of a meaningful activities/recreational program that meets their needs and interests. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Since the last inspection, the range of social and recreational activities has improved. Two part- time activity co-ordinators have been appointed who are responsible for arranging group activities as well as meeting individual interests. One of the activity co-ordinators showed the Inspector individual records that had been prepared showing the activities that residents had taken part in. This information included skills, hobbies and interests as well as goals for residents. The record also included the dates and various activities that Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 14 residents had taken part in and evaluation sheets. Examples of activities available included reading, crosswords and watching television films, games, armchair exercises and reminiscence sessions. Where communication problems had been identified, speech therapy charts had been included with instructions to assist staff. Photos of individual residents were also included. The Inspector was also able to observe reminiscence sessions taking place in the lounge, which stimulated positive interaction between residents and staff. At this particular session there were twenty residents present with four staff and two relatives. This involved the use of large cards with pictures that were meaningful to residents relating to the earlier years of their lives. Residents could also take part in art and craft activities, which also involved the help of volunteers from one of the local churches. Various exercises and puzzles were available to assist residents with word recognition and numeracy. One of the residents said how they had discovered an interest in drawing and how staff had supported her in this activity. The hairdresser told the Inspector how she came in each week and enjoyed the opportunity of having conversations with residents. Where residents required assistance with feeding, the home had also recognised this as an opportunity for staff to have conversations on a one -to -one basis. Some of the residents spoken with confirmed that staff were helpful and are prepared to take them out into the local community. Other residents spoke about how they were able to choose their own preferred daily routines and join in different social activities. Positive comments were made by residents confirming that staff respect privacy, dignity and individual choice. Some residents spoken with said how they enjoyed the privacy of their own room and doing crosswords, jigsaw puzzles as well as sketching. Positive comments were also made by residents about the laundry arrangements in the home and that clothes were kept nice and clean. Positive comments were made by residents regarding the presentation and standard of meals provided and that alternative meals are available to choose from. One of the residents spoken with said that they she had chosen shepherds pie for this particular day. Four- weekly menus confirmed that choices were available which included two main meals as well as other alternatives. Records indicated the meals, which had been provided to individual residents. A cold or hot tea is available for residents which includes soup, mixed sandwiches and other hot snacks. Fresh vegetables are purchased from a local farm and meat with other provisions are also bought locally. Food hygiene courses had been completed by the cooks and up- todate records were available of freezer and refrigerator temperatures. In their self-assessment (AQAA) form, the home state how they have provided a varied menu with seasonal changes as well as removing and including other items as a result of listening to people who use the service. In addition, some changes have been made to the recreational activities following suggestions made at residents meetings. Minutes of these meetings were made available for inspection. The home is planning to expand their activities programme to include baking and gardening as well as including any suggestions made by Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 15 residents and their families. Arrangements are also being made to encourage residents to go out more and to try and arrange for additional entertainment. From conversations, observation and records available, the home has been able to demonstrate its ability to ensure equality and diversity is promoted as part of the quality of life and experience of residents who live in the home. Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 16 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 People who use the service experience good quality outcomes in this area. Residents can expect to have their complaints taken seriously and be assured that they will be protected by the home’s safeguarding adults from harm procedures. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The Statement of Purpose and Service User’s Guide explains the complaints procedure. Since the last inspection, there has been one recorded complaint and evidence was available to show that this was properly dealt with and investigated through the local Social Services department. The complainants were satisfied with the conclusion. Policies and procedures on safeguarding adults from harm were in place and there have been no instances reported where residents have been at risk. Staff spoken with, had an awareness and understanding of the reporting procedures to be used should they be aware of any possible risk to vulnerable adults. Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 17 Residents spoken with said they felt safe in the home and were confident that they could approach staff should they have any concerns. Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 18 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): 19,24 and 26 People who use the service experience good quality outcomes in this area. Residents can expect to live in a clean, safe and comfortable environment. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The premises of the home were clean and hygienic with no offensive odours. No concerns were expressed by residents regarding the cleanliness of their rooms. Liquid soap dispensers and paper towels had been provided in toilet and bathrooms. Since the last inspection, new laundry equipment has been provided, the dining room and at least 50 of the bedrooms have been redecorated and re-carpeted. Residents are able to choose colour schemes for their bedrooms and some have purchased their own curtains. The kitchen Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 19 floor has been renewed and a new dishwasher supplied. Some of the residents spoken with said how much they appreciated and enjoyed the privacy of their own bedrooms. Family photographs, ornaments and personal possessions were also available in residents’ bedrooms and displayed in accordance with individual preference. The home employs their own maintenance person who is available to assist residents in the personalisation of their rooms and provides additional shelving where required. According to the self-assessment (AQAA) form completed by the home, new lighting has been installed throughout all the corridors and communal places. Some of the staff spoken with confirmed that they had completed or were about to receive training in infection control procedures. Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 20 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 People who use the service experience good quality outcomes in this area. Residents can expect to be cared for by suitable numbers of staff on each shift, which meets their needs. Residents can be assured that records will be available to demonstrate that the home has followed robust recruitment and employment procedures. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Staff rotas were available and the normal provision of staff includes the manager, who is supernumerary, with two qualified nurses on duty till 4:30 p.m. One qualified nurse is available from 4:30 p.m. and another covers the night shift. In addition there are two senior care assistants on duty during the waking day with four care assistants covering the early and late shifts respectively. As well as a qualified nurse covering night duty, four care assistants are also available. Other staff include two part time activity coordinators, ancillary staff consisting of two cooks, kitchen assistants, laundry assistant, gardener/handyman and admin support. Staffing levels seemed to be adequate to meet the needs of residents at the time of the site visit. The Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 21 manager said that following comments received from relatives on one of the home’s questionnaires, additional staffing had been provided first thing in the morning and later in the evening. The home would also like to appoint additional activity co-ordinator hours to cover weekends. Recruitment records were checked for recent members of staff who had been appointed. These included proof of identification, two written references, as well as P.O.V.A. First and Criminal Record Bureau disclosures. Letters of appointment and job descriptions had been issued. As well as the manager, eight staff were spoken with during the site visit. Positive comments were made regarding the working relationships which existed within the staff team and that the management were approachable. People enjoyed working in the home and staff confirmed that they had attended a number of training courses. These included moving and handling, fire training, infection control and others confirmed that they had completed induction training based on the Skills for Care model. A record of training courses completed by Staff was available which included infection control (MRSA), food safety and care for the dying. Staff were said to be supportive of each other and staff meetings regularly take place. According to the selfassessment (AQAA) form completed by the home, additional staff have been enrolled on the National Vocational Qualification (NVQ) courses, Levels 2/3. Once these members of staff have successfully completed their NVQ training, this will represent 46 of the staff team having attained NVQ level 2 or above. Other staff have also been enrolled on courses covering dementia training and palliative care. Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 22 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 and 38 People who use the service experienced good quality outcomes in this area. Residents can expect to live and be supported in a home where the management and administration of the service is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The registered provider and manager have continued to develop the service to ensure that it is run in the best interests of residents. An application has been submitted to the Commission for Social Care Inspection for the manager to be registered. The existing manager has considerable experience as a qualified Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 23 nurse both within the public and private sectors. She is currently working towards her Registered Managers Award and National vocational qualification (NVQ) assesses qualification. Evidence is available to show that residents’ meetings have taken place as well as individual conversations and the home has also included some survey questionnaires as a further means of obtaining the views of residents and their relatives regarding the service provided. By doing this, the home have demonstrated that it is prepared to listen to the users of the service with the result that changes and improvements have been made since the last inspection. The Inspector recommendes that instead of sending survey questionnaires to a sample of residents and their families, all users of the service and their families be included. In addition, the Inspector recommendes that health care professionals who regularly visit and are in touch with the home, be included in this exercise. In their self-assessment (AQAA) form, the home has acknowledged the need to encourage outside agencies to complete quality assurance questionnaires. The format and layout of questionnaires should also take into account residents who have a sensory impairment. This would ensure that all residents have the opportunity of expressing their opinions irrespective of their need or disability. Monitoring visits have regularly been undertaken by the responsible individual on behalf of the registered provider and reports were available which had been prepared under Regulation 26 of the Care Homes Regulations. Records and certificates were available to show that maintenance and servicing agreements in relation to the health and safety of the premises were being implemented. These included electrical and gas safety, portable appliance testing, mechanical aids and hoists as well as maintenance checks carried out on the shaft lift. Records were available of hot water temperatures and prevention of legionella. A sample check of water temperatures showed that these were not hot to the touch and were safe at the time of inspection. A fire risk assessment was in place, which had been recently updated following a visit and recent advice given by the fire officer. The Inspector advised the manager to seek clarification from the Essex Fire and Rescue Service regarding evacuation procedures and the responsibilities of staff in these situations. Records were available of fire precaution procedures and other checks, which had been made in the home. Regular staff supervision sessions take place and records were available but some staff spoken with, said that they could not recall having supervision recently. A sample check was made of records relating to personal allowances held by the home on behalf of residents. Records of financial transactions were detailed and were consistent with the balance of money being held at the time Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 24 of inspection. Two staff signatures had been provided with all transactions and receipts were available. Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 25 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 4 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 OP7 Good Practice Recommendations The process of updating and personalising all care plans should be continued and completed to reflect clearer details regarding identified needs and how these should be met. Issues regarding prescription dispensing should be addressed with the local pharmacist to ensure medication procedures are followed in accordance with guidance issued by the Royal Pharmaceutical Society. The home should aim for at least 50 of care staff to achieve National Vocational Qualification (NVQ) Level 2. The quality assurrance procedures of the home should take into account the views of all users of the service, relatives and other health care professionals. Appropriate formats of survey forms should be made available to people who require them. Further clarification should be sought from the Fire Officer regarding evacuation procedures and the expectations of DS0000068042.V358374.R01.S.doc Version 5.2 Page 27 2. OP9 3. 4. OP30 OP33 5. OP38 Primecare Nursing Home staff in emergency situations. Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Primecare Nursing Home DS0000068042.V358374.R01.S.doc Version 5.2 Page 29 - 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. 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