Inspection on 17/01/07 for Primley Court Nursing Home

This inspection was carried out on 17th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Primley Court Nursing Home 25/11/05

Primley Court Nursing Home 05/08/05

Primley Court Nursing Home 16/02/05

Primley Court Nursing Home 14/09/04

Primley Court Nursing Home 08/05/03

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Primley Court Nursing Home Optima Care Partnership 13 Primley Park Paignton Devon TQ3 3JP Lead Inspector Doug Endean Unannounced Inspection 17th January 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Primley Court Nursing Home DS0000028755.V319886.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. Primley Court Nursing Home DS0000028755.V319886.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Primley Court Nursing Home Address Optima Care Partnership 13 Primley Park Paignton Devon TQ3 3JP 01803 555988 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) Optima Care Partnership Mrs Monica Anne Gumus Care Home with Nursing 52 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (52), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (52), Old age, not falling within any other category (6), Physical disability over 65 years of age (6) Primley Court Nursing Home DS0000028755.V319886.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Registered for maximum 6 OP Registered for maximum 6 PD(E) service users 65 years and over Registered for maximum 52 DE(E) service users 65 years and over Registered for maximum 52 MD(E) service users 65 years and over The home may admit up to 5 service users between the ages of 55 years to 65 years with a diagnosis of Early Onset Dementia (DE) 25/11/05 Date of last inspection Brief Description of the Service: Primley Court is a purpose built 52-bedded care home providing personal and Nursing care to older people primarily with mental health problems who may also have physical frailties. The home is one of a group owned by Optima Care Partnership that is spread over the South West of England. The accommodation is arranged over a number of floors with a choice of lounge and dining facilities. Half of the property is a new build that provides accommodation that exceeds the National Minimum Standards in terms of size of rooms and facilities. The rest of the home has been redecorated to a good standard. The lower ground floor accommodates the Registered Manager’s office, kitchen and staff room and also provides level entry to Service Users and their visitors who can then use one of the two shaft lifts to access the rest of the home. A further nursing office is located on the ground floor opposite the front door. Being located on a high elevation, and close to Paignton town centre, there are some excellent views from some rooms over the town and Torbay. The bedrooms are mainly single and 31 have en-suite facilities. As the home provides nursing care it always has a registered nurse in charge of each shift. The Registered Manager is a very experienced Registered Nurse with management skills and has achieved the Registered Managers Award at National Vocational Qualification level 4. The home has also been awarded the Investors in People Award in February 2004. The home has a condition of registration to enable them to admit up to five clients between the ages of 55 years to 65 years old who have a diagnosis of Young Onset Dementia. The homes fee’s commence at £438.35 for personal care and increase with National Health Service nursing care funding. Primley Court Nursing Home DS0000028755.V319886.R01.S.doc Version 5.2 Page 5 Primley Court Nursing Home DS0000028755.V319886.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on the 17th January 2007 beginning at 10:00 hours and lasted six hours. The Registered Manager or one of the Registered Nurses was always available to assist the inspector during this time. The Registered Manager had also prepared the Pre-Inspection form and additional information to assist the process. The inspector read four service users records and four staff files. He spoke to service users during his tour of the establishment and interviewed three members of staff. The Group Engineer was in the home at the time of the inspection and provided the inspector with evidence of how the home has continued to be maintained to a high standard. The inspector had also received three completed care staff survey forms and nine completed relative comment cards What the service does well: What has improved since the last inspection? What they could do better: The home provides an excellent service overall. Primley Court Nursing Home DS0000028755.V319886.R01.S.doc Version 5.2 Page 7 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. Primley Court Nursing Home DS0000028755.V319886.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 Primley Court Nursing Home DS0000028755.V319886.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): The homes performance was assessed against Standard 1, 2, 3, 4, and 5. Standard 6 is not applicable. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The information made available to service users does provide them with clear statements about the service they can expect to receive. The Registered Manager is able to demonstrate the homes ability to meet the assessed needs of prospective service users and those already resident in the home. EVIDENCE: The Registered Manager showed the inspector a completed copy of the new format that is now used by the group to gather information about prospective service users. This document is very comprehensive and gathers valuable information regarding the service users mental health issues and physical well being. This has replaced the earlier document that was seen in many of the files of service users who have lived at Primley Court for some time. The Primley Court Nursing Home DS0000028755.V319886.R01.S.doc Version 5.2 Page 10 inspector read a sample of four of the previous pre inspection formats as part of the case tracking process. The information gathered by both formats is more than sufficient for the home to make a judgement about the suitability of the prospective service users to become resident at the home. Prospective service users and their advocates have a well prepared Statement of Purpose and service users guide available to them that offers clear information about the service they can expect from the home should they wish to become resident there. The home is happy to have service users and their advocates visit the home prior to any agreement to admit. They also have day care services for a small number of individuals that operates seven days a week. The homes terms and conditions of residence, or contract, allows for the first month to be on a trial basis. The fee’s structure is included in the contract and is clearly stated where the service is contracted by the Local Authority including the National Health Services nurse determination payment. It also informs the service users about how the payment for the service is to be made. Additional leaflets written by a national organisation is made available to everyone visiting the building that is entitled “Taking the worry out of paying for care”. The leaflets are attached to the notice board above the signing in book on the lower ground floor next to the shaft lift. The Registered Manager was able to demonstrate that the home has the capacity to meet the various needs of the service users who primarily suffer from dementia but are also, in many cases, frail elderly individuals. The design of the building is good and incorporates many aids for the disabled such as shaft lifts and disabled bathing facilities as well as a variety of communal areas for activities or tranquil moments. The staffing arrangements are excellent with a skill mix of trained nurses on duty supported by experience care staff. Primley Court Nursing Home DS0000028755.V319886.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): The homes performance was assessed against Standard 7, 8, 9 and 10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home produces care plans that are well structured, clear to read and understand and based on an excellent ongoing assessment process. The way that staff delivered care met the needs of the service users and maintained their dignity. EVIDENCE: The inspector reviewed the files of four service users as part of case tracking. He found that each file was well structured beginning with an information sheet about the individual service user. There were well-written care plans that were supported by the information gathered during the initial and subsequent assessments. Risk assessments included Waterlow, nutrition, falls and mental health assessment. There is also a risk assessment completed when the use of bed guards (bed rails) has been considered. The inspector saw one example of this assessment. There is a 20-point functional assessment covering the Primley Court Nursing Home DS0000028755.V319886.R01.S.doc Version 5.2 Page 12 physical and mental health of the service user in each file. A score was produced that identified the level of disability and this assessment was repeated monthly. There was also a monthly record of weight, temperature pulse and respiration. The home has identified individual issues of care needs that need to be addressed and produced individual care plans that are regularly reviewed. The service users progress is recorded in notes made by the staff and also by the chiropodist that visits the home weekly. There are separate notes recording information about Doctors visits. The home has its own activities staff who also have their own sheet to record activities that each service user has been involved in and their response to the activity. The handling and administration of medication is the responsibility of the trained nurses who work at the home. The storage arrangements for medication are secure. The administration records are good. There is a copy of the signature of staff who administrate medications for purpose of identification. The home also has suitable policies and procedure information relating to medications including homely remedies, and there is reference material for staff to refer to about the drugs that are in use. The staff was seen to deliver care in a manner that showed an understanding of maintaining dignity. They communicated in a respectful way addressing the service users by names that they appeared comfortable with and provided personal care in private. Service users were dressed in their own cloths that are mainly laundered by the home. Primley Court Nursing Home DS0000028755.V319886.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): The homes performance was assessed against Standard 12,13,14 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The attention to social and therapeutic activities to benefit the service users is very good. The preparation and presentation of the food given to the service users is excellent. EVIDENCE: The home enquires about the past hobbies and interests of the service users and records this information. They employ a full time Activities Organiser and also one other person who works three afternoons a week on activities. They have their own office within the home. The service users records have a separate sheet that is used to record the activity and individual has taken part in and what level of involvement and enjoyment they received from it. The inspector read a number of these notes. The Manager told the inspector that on occasions the home hires an eight-seat people carrier to take service users out for a drive. The service users had seen the Christmas lights and been on short trips such as to the steam railway. Other activities recorded in the pre Primley Court Nursing Home DS0000028755.V319886.R01.S.doc Version 5.2 Page 14 inspection form are reminiscence, quizzes based on specific eras, handicraft to improve manual dexterity and divisional therapy to alleviate stress. Nine relatives did respond to the request for information on the Commission for Social Care Inspection comment card. All nine had positive comments such as “I miss her very much but Primley Court puts my mind at rest”. Another said “The best home in Devon run by angles”. Finally one said” I am very pleased with the care given to my relative. The home is always very clean and the patient’s have lots of attention. The food is good and varied. The staff always welcome us as visitors. I would like to see some more entertainment”. There is a “shop” now in the home on the lower ground floor with its goods laid out such as sweets, toiletries, tights and socks, tooth brushes, etc. The shop is open each afternoon and run by a member of the relatives group “Friend of Primley Court”. Staff take service users to the shop where they can spend their money and the profits are to purchase items for the home for use by the service users. The relatives group arrange their own meetings within the home. Visiting can take place at any reasonable time in the home and there are several areas, including the service users own room where service users can spend time with their friend or relative. The home hosts a Religious service every Tuesday in the home for Roman Catholics and one Sunday afternoon a month for Methodists and Baptists. The Church of England has not made any arrangements to carry out a service at the home. The home will take the service users to the church, or any organisation, if they express a wish to attend. The service users are helped where necessary to achieve choice in many ways including voting, activities, cloths they wear and where they choose to be in the home. The Service Users are not able to manage their own financial affairs. The home does provide guidance for their advocate to make secure arrangements should they need it. The tour of the home provided the inspector with evidence that the service users have their bedrooms decorated with their own belongings. The rooms are lockable and where it is possible keys can be provided following a risk assessment. The inspector saw the main meal of the day being freshly prepared and later being served. There was a choice of the main meal and the service users (who could make a choice) were asked what they would prefer prior to the meal and at the time the meal was served. The food was very well presented, of good portions, and had a nice aroma. The service users spoken to during the meal said that they were very happy with the meal they had received. The kitchen was very organized and the chef had his Safer Food, Better Business records available for inspection. The Manager told the inspector that the service users have a record of likes and dislikes regarding food, in their files. This was verified during the inspection. There was also a nutritional assessment made that helped the chef produce each meal in a way that was palatable to the individual such as normal presentation or pureed. Primley Court Nursing Home DS0000028755.V319886.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has satisfactory arrangements for the reporting of a complaint. The staff has received satisfactory levels of training on the subject of abuse. EVIDENCE: The home has a detailed complaints procedure that is made available to Service Users and visitors to the home that includes how to contact the Commission for Social Care Inspection. The procedure is displayed at the entrance of the home, in the Statement of Purpose and also the Service Users Guide. The home has a book to record any complaints in along with the outcomes following an investigation that was seen by the inspector. The home stated that they have not had any complaints raised since the last inspection. The Commission for Social Care Inspection has also not had any complaints raised since the last inspection. The inspector saw a record of the homes in house Adult Protection training that is an ongoing process. The Manager also said that Adult Protection training is received as a part of the “Skills for Care “ Induction training that staff attend. In addition to this the inspector saw evidence that staff are now also attending Protection of Vulnerable Adult Training run by the Local Authority as places become available. There are satisfactory policies and procedures in place for staff to follow should any suggestion of abuse occur. Primley Court Nursing Home DS0000028755.V319886.R01.S.doc Version 5.2 Page 16 The home does not handle the finances of service users and any purchases for them are supported by invoices and receipts dealt with at head office. Primley Court Nursing Home DS0000028755.V319886.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 19, 20, 21, 23, 24, 25 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is a good design, which provides space and facilities that meet the needs of the service users such as several lounges and dining areas. The maintenance program is very well planned and executed. The equipment is of good quality and fit for the purpose. EVIDENCE: The home is purpose built having initially been a rebuild maintaining the exterior appearance of the old structure in 1995. It now benefits from a brand new extension designed to exceed the standards and meet the needs of this specific service user group. The home complies with Building Control, Fire and Environmental Health requirements. It has tidy grounds, good parking space, Primley Court Nursing Home DS0000028755.V319886.R01.S.doc Version 5.2 Page 18 and good access with the benefit of two shaft lifts that can access every floor of the home. The older part of the building has undergone a full re-decoration and refurbishment, so as to meet the standard reached by the new build. Maintenance is carried out to a very high standard both by the in house handy man and also by the Group Engineer. The Group Engineer was at the home during the inspection. He provided evidence on computer and hard copy that showed that all the requirements of building and equipment maintenance were up to date including the fire equipment and emergency lighting, hoists and lifts and portable electrical appliance testing. Radiators are maintained at a safe temperature level through a system management approach and the new build has low surface temperature radiators. The inspector’s tour of the building provided evidence that the home is clean, warm, well decorated and that service users rooms had been personalised with their own possessions. There is ample communal space such as lounges, dining rooms and a conservatory. The communal space in the new build has air conditioning. There is a nurse call system through out the whole home. There are 43 single bedrooms and 4 double bedrooms. A total of 28 singles and 3 double bedrooms have en suite facilities of good size and disabled facilities. Screens are provided between beds in double rooms. Most bedrooms exceed the minimum requirement of size and equipment level with beds being domestic in appearance but are equipped to have the height and position adjusted electronically. Bedrooms can be locked and keys supplied to service users if a risk assessment suggests that this is appropriate. The bathrooms bath tubs that have integral hoists that allow the service users to raised out of the bath in a seated position. There are also wet rooms (shower rooms) that have purpose built mobile seating and good space to allow the more independent to manage themselves in this area of personal care. Outside of the en-suites there are disabled toilets available near the communal spaces and near the bedrooms that do not have en-suites. The home also has macerator-sluicing facilities in their own rooms that are separate from any other facility. All the baths and sinks used by the service users have a thermostatic control valve to reduce the risk of scalding. These are also managed under the homes maintenance scheme. The home has suitable arrangements for the protection of service users and staff from Legionella through good practice, and maintenance and records have been seen by the inspector to support this. The laundry meets the requirements of having impermeable floor covering and washable walls. It is equipped with modern machinery that is suitable for the task such as the washing machines having a sluicing cycle. The laundry is in a building separate to the home and dirty laundry does not have to pass through any food preparation areas. There is also a hair dressing salon in the new extension for the service users that is presently attended by a hairdresser once a week. The manager told the inspector that the hairdresser will soon be working full time at the home. Primley Court Nursing Home DS0000028755.V319886.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 27, 28, 29 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has good recruitment practices. The staff are well prepared for the work that they are involved in through good training. There are sufficient numbers of experienced staff on duty at all times. EVIDENCE: The home is staffed by trained nurses, and trained care staff, in sufficient numbers to meet the assessed needs of the service users resident at the home. The skill mix includes a minimum of two registered nurses during the hours of 08:00 and 20:00 each day supported by nine care staff. During the Registered Managers administration days the registered nurse number in the building raises to three from both general and psychiatric nursing backgrounds. The inspector saw a number of duty sheets, including the one for the week of this inspection, which showed that there had been good planning to provide sufficient levels of staff of all grades at all times. The staff records and pre-inspection format provided evidence that the staff, nurses and care staff have maintained a regular educational update following their induction into the home. The home has the “Skills for Care” training manuals and use the learning portfolio’s to demonstrate the skill taught and learned by care staff who complete a six month comprehensive induction Primley Court Nursing Home DS0000028755.V319886.R01.S.doc Version 5.2 Page 20 program. The home commence the induction with their own program in the first two weeks of employment that includes fire instruction, manual handling and “whose who”. The inspector saw evidence of the following training having been undertaken by individuals, “Safer food, Better Business” by Torbay Environmental Health Department, Falls Training by Torbay Hospital and Fire Training by an external provider of fire training. The care staff have also attended training in dementia, mental; health and challenging behaviour that is client specific to this home. Four staff files were read that provided evidence that the home follows the recruitment procedure and Schedule 2 of the Care Homes Regulations when vetting staff. They obtain references, a Criminal Records Bureau check, means of identification and carry out a equal opportunities interview recording the responses and outcome. Work permits were seen for staff that have been employed and originate outside of the European Community. Contracts were seen in the staff files that included the terms and conditions of employment and were signed. Staff files are quality assured to maintain a good standard and the inspector saw the record of this. The home has achieved 43 of the staff with a National Vocational Qualification at level 2 or above and 17 of the total are currently taking the National Vocational Qualification at level 2. A total of 13 staff also had the certificate in First Aid. The home operates a key worker system that care staff reporting to a registered nurse who would generally also be their supervisor. The number of service users allocated to key workers is calculated on the number of hours that they are contracted to work. The inspector interviewed three staff members, one employed as a trained nurse and two employed as care staff. Each were complimentary about the home and the standards that they achieve. They felt the level of training was high and that it prepared them for the job. They also felt that the staff group worked well together and learnt from each other. One of the staff was from overseas and commented how friendly the multicultural staff group were and how they helped each other to improve their skills and command of English. Three staff survey forms were received. Each was complimentary about the home and the standard of care they achieve. One staff member felt that the service users may benefit from coming together more for entertainment. They also felt that they would benefit from more personal supervision. Primley Court Nursing Home DS0000028755.V319886.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The homes performance was assessed against Standard 31, 32, 33, 35 and 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is managed very well both by the Registered Manager and the Registered Individual. The staff team are led well by the Registered Manager to achieve the aims and objectives of the service. The overall management of the service has enabled it to meet the health, safety and welfare needs of the service users. EVIDENCE: The Registered Manager is an experienced Mental Health Nurse who has managed care homes for several years. She has the Registered Managers Award at National Vocational Qualification level 4. The manager is a good Primley Court Nursing Home DS0000028755.V319886.R01.S.doc Version 5.2 Page 22 advocate for the service users at the home and achieves great success in developing the work force in order to achieve the homes aims and objectives. This was recognised when it achieved the Investors in People Award” in February 2004. The calm measured approach that she takes in all her duties has been well received by those that she meets in the course of her work. The Registered Individual also plays his part in managing the home and prepares Regulation 26 notices on a regular basis for the Commission for Social Care Inspection reporting on the homes conduct. This forms a part of the homes overall quality assurance process that also includes obtaining the views of the service users or their advocates every three months, and the staff, about how the home is performing. The inspector saw evidence of other ways that quality outcomes are measured such as the total recruitment process for staff. The home does not involve itself in the management of any of the Service Users financial affairs. Where Service Users cannot manage their affairs for themselves someone has been appointed to do this for them, usually a family member. The home does however manage small amounts of pocket money and has full accounting records for any transactions. There is short term secure facilities for valuables should this become necessary. Property sheets were seen in the back of Service Users files with signatures agreeing to the record that has been taken. The Registered Manager has shown through the course of this inspection how she, and the Registered Individual, have managed the home in a way that meets the heath, safety and welfare of the service users. The staff are trained in appropriate skills to meet the service users needs. They are provided with good levels of well maintained equipment to deliver care in a way that protects the service users and the staff from unnecessary risks. The environment is well maintained by the in house maintenance man and the group engineer. The home is kept clean and free of clutter that could be a risk to service users. Where it becomes necessary the Registered Manager, or another registered nurse, will obtain another health care professionals advice on how to best meet the needs of the service users. Primley Court Nursing Home DS0000028755.V319886.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 3 4 4 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 X 4 4 3 3 STAFFING Standard No Score 27 4 28 4 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 3 X X 4 Primley Court Nursing Home DS0000028755.V319886.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP28 Good Practice Recommendations Maintain efforts to achieve 50 of staff achieving the National Vocational Qualification level 2 in care. Primley Court Nursing Home DS0000028755.V319886.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Primley Court Nursing Home DS0000028755.V319886.R01.S.doc Version 5.2 Page 26 - 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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