Inspection on 20/12/07 for Primley House

This inspection was carried out on 20th December 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 House 21/09/06

Primley House 05/10/05

Primley House 10/05/05

Primley House 23/08/04

Primley House 07/04/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Primley House Totnes Road Paignton Devon TQ3 3SB Lead Inspector Peter Wood Key Unannounced Inspection 20 December 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 House DS0000018413.V350857.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 House DS0000018413.V350857.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Primley House Address Totnes Road Paignton Devon TQ3 3SB 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) 01803 558867 01803 558867 primleyhouse@tiscali.co.uk Primley Housing Association Limited Mrs Gail Collings Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places Primley House DS0000018413.V350857.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st September 2006 Brief Description of the Service: Primley House provides care for up to thirty-nine older people. It is a beautiful old house set in its own well-maintained grounds, which are frequented by peacocks, near Paignton Zoo. Indeed, the house was the original zoo, latterly the home of the original owner. Entrance to the house is by shallow steps or a ramp to the side for people who cannot manage the steps. The front door leads into a very large hall that has seating areas. The ground floor comprises a large library, large lounge that can be separated into two rooms, a long sun lounge, and a large dining room. There is also an office, treatment room, kitchen with numerous store rooms, separate staff, mens, womens and accessible toilets for people who live in the home, and a shower room. There are 8 single en-suite bedrooms on the ground floor, 3 of which have en-suite baths. There is a grand staircase, and also a shaft lift, to the first floor, which has a further twenty-two single en-suite bedrooms, 7 of which have en-suite baths. There are 3 double bedrooms, all with en-suite baths, and a flat, which has a double bedroom, lounge and bathroom. There are a further 2 communal assisted bathrooms, both with toilets, and a further separate toilet. There is also a flat on the second floor where previous managers used to live. This has recently been converted into an office used by the financial administrator, and staff room with kitchen. Fees range between £350 and £400. Copies of inspection reports are displayed in the front hall for people who live in the homes and visitors to refer to. They can also be obtained from the CSCI website. Primley House DS0000018413.V350857.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day in December 2007. The focus of this inspection was to inspect all key standards and to seek the views of people who live in the home, staff, relatives and professional visitors to the home, the latter mainly using survey forms. At the time of writing this report five staff returned the “Care Workers Survey” form. No “General Practitioners Comments Cards” were returned. One “Health and Social Care Professionals in Contact with the Care Home” returned a form. One relative returned a survey form. Nine “Have your say about Primley House” survey forms were received from people who live in the home, and several people who live in the home were consulted during the inspection visit. Some staff were consulted while they were undertaking their duties. Considerable time was spent with the Registered Manager examining documentation, particularly that relating to client assessment and care planning, staffing and health and safety. A full tour of the building was undertaken. The inspection process also includes a review of the Annual Quality Assurance Assessment (AQAA) questionnaire completed by the manager, which is extensively quoted throughout this report. What the service does well: The manager writes in the Annual Quality Assurance Assessment (AQAA) that: • • • • • • • • • • Primley House Residents are given a choice at meal times this is recorded on menu sheets that are put on the dining room tables each day. Residents are provided with a taxi service to town twice weekly A hairdressers visits weekly Chiropodist visits once a fortnight. Residents are subsidised part payment for this Fresh coffee is available for people visiting Primley at all times which is situated in the foyer. Professionals when visiting always comment how friendly staff are and how Primley always looks clean and smells fresh Library books are delivered to the home which includes large print books Holy Communion is offered twice a month A Church service is provided by Gerston Chapel every other Tuesday afternoon Fresh water coolers provided on tap with juice if required DS0000018413.V350857.R01.S.doc Version 5.2 Page 6 • A shop trolley and Birthday cards are provided for residents to purchase things required”. A staff member sums up the particular characteristics of what Primley House has to offer people who live there: “Excellent dedicated Entertainments Coordinator Good choice and quality of food Provides a comfortable, safe environment for our staff and residents. Good access of services both in and out of the home Provides hard working, dedicated carers”. Assessments prior to admission allow people to be confident that their health, personal and social care needs can be met. These needs are met and they are treated respectfully. The home’s practices relating to medication protect them from risk. The home provides varied social activities. People who live there maintain contact with their friends and families and are encouraged to exercise as much choice and control over their lives as possible. Meals are nutritious and varied, taken in the restaurant style dining room. Complaints are treated seriously. People who live in the home are listened to and issues resolved promptly. People who live in the home enjoy a pleasant, well-maintained comfortable home that provides more than sufficient facilities to meet their needs. They are cared for by trained staff in sufficient numbers to meet their needs. Recruitment processes protect vulnerable people who live there. This is an excellent, well-managed home, run in the best interests of the people who live there. What has improved since the last inspection? What they could do better: Primley House DS0000018413.V350857.R01.S.doc Version 5.2 Page 7 The manager writes in the Annual Quality Assurance Assessment (AQAA) that: “Residents have requested that staff spend more one to one time with them, besides the Keyworker system. At this moment in time we are having Criminal Record Bureau checks undertaken for voluntary people to come into the home to provide one to one talks with residents, especially with those who have no families. The home meets all the National Minimum Standards. The home continues to improve, managed by a skilled manager very well supported by an active and able committee. The home is commended for its quality and encouraged to continue the progress. 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 House DS0000018413.V350857.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 House DS0000018413.V350857.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): 1, 2, 3, 4, 5, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments undertaken prior to admission allow people who may come to live in the home and their relatives to be confident that their needs can be met. They are encouraged to visit prior to admission. The home does not offer intermediate care. EVIDENCE: The manager writes in the Annual Quality Assurance Assessment (AQAA) that: “By inviting prospective clients to come and look around, stay for the day to have opportunities for experiencing the environment they will be living in, this gives them a chance to talk with others who already reside at Primley. A brochure is available for them. A pre-assessment form is undertaken by the Manager or Assistant Manager. A new form has also been introduced so we are able to fully assess prospective clients and to see if the clients’ needs will be Primley House DS0000018413.V350857.R01.S.doc Version 5.2 Page 10 provided with the registration we offer. We also offer day care so someone thinking about coming in to care could have a trial visit.” As part of the inspection process we (The Commission for Social Care Inspection, hereafter referred to as ‘we’) examined assessment documentation of four people who live in the home. Examination of this documentation, consultations with and questionnaire returns from the manager, staff, relatives, visiting professionals and people who live in the home substantially evidence the statements as above. Primley House is one of the well-known houses in Paignton and produces a brochure, which describes the house and its history, and the structure of and care provided by the care home. Primley House receives prior to their admission assessment documentation from Torbay Care Trust, or other local authority or care trust, to identify the needs of people who are care managed by those authorities who may come to live in the home. This is invariably followed up by the manager or her assistant undertaking their own assessment, usually by visiting the home of the prospective client. This would usually be the only pre-assessment in respect of those clients who are not care managed. These processes help to ensure that the home is able to meet their needs. People who live in the home said that they and their families had been able to visit the home before making a decision to move in. Indeed, this is the norm for this home. Many current people who live in the home had been to visit, stay for lunch or over a day, or experience a period of day care or before making application to move in. Prospective clients are therefore given every opportunity to “try before they buy”. They and their relatives are assured that only those people whose needs the home can meet are admitted, and they are given a contract / statement of conditions when they have decided to stay. The home does not offer intermediate care. Primley House DS0000018413.V350857.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, 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of people who live in the home are met and they are treated respectfully. The home’s practices relating to medication administration protect them from risk. EVIDENCE: The manager writes in the Annual Quality Assurance Assessment (AQAA) that: “We make sure that the new clients who are admitted to our home are suitable so that the home stays the way it is and other clients are not going to be effected by the sort of client we admit. We do well as clients stay with us and are happy not to move somewhere else to live. We have a number of clients who have been at Primley for quite a few years not wanting to move anywhere else. Also clients have come from other homes.” As part of the inspection process we examined care planning documentation of four people who live in the home. Examination of this documentation, Primley House DS0000018413.V350857.R01.S.doc Version 5.2 Page 12 consultations with and questionnaire returns from the manager, staff, relatives, visiting professionals and people who live in the home substantially evidence the statements as above. Detailed assessments were recorded upon admission and on significant change. These described the care needs of people who live in the home which generate the individual care plans. These plans have been revised following a recommendation at the last inspection. The documentation now uses an integrated Standex system, which has removed the previous duplication of documentation, for the separate use of seniors and care staff. This new system avoids not only unnecessary effort but also potential errors. These care plans are available for all care staff to look at and fill in as required but also people who live in the home can see for themselves. People who live in the home confirmed that they feel very well cared for and can ask at any time for assistance. Documentation confirmed that medical, nursing, and other needs and services, such as that from the rehabilitation officer for visually impaired people, are identified and sought. As part of the inspection process we witnessed the tea time medication round. This evidenced that the home’s policies and procedures were properly implemented. Medication administration records were well maintained. Medication was stored safely, including those in the rooms of people who selfmedicate. This home tries very hard indeed to involve all staff, relatives but especially people who live in the home in as many areas of running the home as possible. They are encouraged to exercise as much choice as possible. People who live in the home confirmed this was the case. Meeting including people who live in the home are regularly held. We saw that staff respect the privacy and dignity of people who live in the home in the way they addressed and spoke about them. Staff knocked and waited for a response prior to entering bedrooms, and sought their permission before going into their rooms on other occasions. While their health and personal needs are met, some people who live in the home commented at the last inspection that owing to the increasing dependency of many fellow people who live in the home, staff were too busy to spend time talking to them or attending to them in such areas as cutting their nails. In response to these comments, which were also raised in residents’ meetings, additional staff have been recruited, supplemented by volunteers who spend social time with people who live in the home. The following comments from staff indicate that staff take pride in their work. [We] “Help the clients feel part of a new family. Encourage them to maintain their interest and independence. Encourage their friends and relatives to visit and support them when necessary. Provide good food. Give them the Primley House DS0000018413.V350857.R01.S.doc Version 5.2 Page 13 opportunities to join in activities and outings. Provide caring staff who are interested in ensuring they achieve the client’s full potential in day to day life”. Primley House DS0000018413.V350857.R01.S.doc Version 5.2 Page 14 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, 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides varied social activities. People who live there maintain contact with their friends and families and are encouraged to exercise as much choice and control over their lives as possible. Meals are nutritious and varied, taken in the restaurant style dining room. EVIDENCE: The manager writes in the Annual Quality Assurance Assessment (AQAA) that: “Activitity Co-ordinator discussions, trips out, entertainment, slides shows, games. Something is held each day for Residents with the activity coordinator. This is highlighted on the two notice boards so all residents are able to see what is gong on daily. We also have different things on some evenings provided by the Friends of Primley. For all these activities it is the residents’ choice if they wish to participate. We also arrange trips out in the mini-bus either stopping off somewhere for a cream tea, sight seeing, or stopping for an ice cream. We try to make sure all clients are offered this facility even in wheelchairs as they enjoy going out. We also have pre-drinks on Saturdays and Sundays to encourage Residents to socialise. The home has provided the Primley House DS0000018413.V350857.R01.S.doc Version 5.2 Page 15 service of Sky TV within rooms and communal areas. We have employed more care staff also have had volunteers coming in to Primley.” As part of the inspection process we consulted several people who live in the home. We also consulted the manager and staff. We examined documentation in the home and questionnaire returns from staff, relatives, visiting professionals and people who live in the home. Examination of this documentation and consultations substantially confirm the statements as above. Many people who live in this home continue enjoying as much of their previous lifestyle as possible. Several maintain contact with friends and clubs previously attended. The home engages the services of an Activity Co-ordinator who arranges some sort of activity every day. Some relatives and friends also help with the organisation and delivery of some of these activities, examples of which are themed occasions like Mothers’ Day, Easter, and Christmas. They also had a Hawaiian theme day during which staff dressed up and Hawaiian food offered. Not all people who live at the home wished to eat this food so were offered alternative meals. The home tries to encourage clients to come up with ideas for themed occasions therefore involving them to make the choice. Most activities are planned in advance with the people who live in the home. A notice board provides information about the activities offered and other matters of interest to people who live there. People who live in the home commented that they can chose which activities they wish to participate in and how much they enjoy these. Their relatives and friends are invited as well. A record is kept of the trips to local places of interest. People who live in the home are encouraged to do as much for themselves as possible, rather than becoming dependent on staff. For example, people who live in the home are encouraged to do their own shopping, and a free bus to the shops is provided twice a week. A Sensory Garden was officially opened by the Head Gardener of Paignton Zoo on 1st December 2007 so that people who live in the home can involve themselves with gardening. People who live in the home told us that the food was plentiful and very good. “I have lived here for [several] years and always enjoy the food. Fresh vegetables always (except peas) nicely cooked, and fresh fruit provided daily. Always an alternative to the set menu if we wish. The chef and staff do a good job considering the large number of residents with differing tastes”. The dedicated chef is knowledgeable about nutrition and the dietary needs and preferences of people who live in there. Most people who live in the home choose to take their meals in the very pleasant dining room, though they can have meals in their own room if they prefer. Drinks and snacks are available at all times to people and their visitors: water fountains provide excellent cool water whilst a coffee percolator, currently moved from the front hall to the library, is well used. Primley House DS0000018413.V350857.R01.S.doc Version 5.2 Page 16 Staff commented that the home: “Makes sure that all service users are made to feel individual in maintaining their dignity, self respect and promoting independence”. People who live in the home commented: “The staff are all good, caring people, and I consider myself very fortunate to live in such a lovely home”. “I hope that I may live here for the rest of my life”. “I am very happy and comfortable at Primley”. However, recognising that more dependent people are being admitted to the home one person comments: “The staff do the jobs they have to do. I feel that there is more nursing needed than when I first came here, therefore they are sometimes less happy than they could be, and less relaxed”. In response additional staff have been employed and extra staff on rota during times of heavy demand. Primley House DS0000018413.V350857.R01.S.doc Version 5.2 Page 17 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, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints and suggestions from people who live in the home, their relatives or other visitors to the home are treated seriously. People who live in the home are listened to and issues resolved promptly. EVIDENCE: The manager writes in the Annual Quality Assurance Assessment (AQAA) that: “The Complaints Policy is situated on the Notice Board for everyone to read. The Residents also have information within their handbook. All Residents have a copy of this within their rooms. Details are also written within the Statement of Purpose. Any complaints are taken seriously and dealt with as quickly as possible. With regards to protection we take serious actions to make sure all our residents are safe at all times. When staff start work at Primley this topic is discussed in great detail so they understand what is acceptable whilst caring for the residents. They also watch the ‘No Secrets’ video. We also make sure that staff attend The Protection of Vulnerable Adults Alerter’s Course.” As part of the inspection process we consulted several people who live in the home. We also consulted the manager and staff. We examined documentation in the home and questionnaire returns from staff, relatives, visiting professionals and people who live in the home. Examination of this Primley House DS0000018413.V350857.R01.S.doc Version 5.2 Page 18 documentation and consultations substantially confirm the statements as above. The home has a complaints procedure available to all people who live in the home and visitors to the home, and detailed in the home’s Service User Guide. This includes a book for recording complaints. Although this is rarely used, it nevertheless indicates what issues staff and people who live in the home consider to be worthy of formally writing down. Most issues are resolved in advance through the residents meetings and discussions with the manager. People who live in the home said that the staff, manager and committee members were very approachable and they were confident that any issues of concern would be listened to and dealt with. Photographs of the committee displayed on a board in the entrance hall assists people who live in the home to recognise members of the committee who visit regularly. The chair visits several times each week. Photographs and the names of all staff members are kept in a book in the hall to refresh the memories of people who live in the home. Staff have received training in issues relating to abuse and the protection of vulnerable adults, and the home’s whistle blowing policy has been used. This indicates that staff are confident in raising any concerns they may have about practices in the home. The home is currently trying to devise an appropriate recording methodology that would benefit both staff and people who live in the home when staff have gone that extra mile with the care they deliver which can be used as evidence for staff’s NVQs (National Vocational Qualifications) and is kept within their own records. Primley House DS0000018413.V350857.R01.S.doc Version 5.2 Page 19 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, 20, 21, 23, 24, 25, 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who live in the home enjoy a pleasant, well-maintained comfortable home that provides more than sufficient facilities to meet their needs. EVIDENCE: The manager writes in the Annual Quality Assurance Assessment (AQAA) that: “We make sure that all our residents live in a safe, comfortable environment ensuring that everything has been achieved to requirement and design for the benefit of Residents and staff so they are able to maintain a good safe quality of life. All communal areas are clean, warm and well ventilated. We make things happen with reflection on environment i.e. washing machines - new dosage systems - dishwasher – dispenser fitted – cleaning agents – appropriate cleaning systems with right dosage – outside home decorated – safe ultra flooring fitted in toilet upstairs and a residents’ toilet. Hand wash gel Primley House DS0000018413.V350857.R01.S.doc Version 5.2 Page 20 on entry of the home to help with infection control. Provided the facility of Sky TV within individual rooms and communal areas. Providing training for staff relevant for their role. Health and Safety, Moving and Handling, First Aid. Gloves and aprons supplied for all staff. We are at the moment planning to have our own Fire Officer who will come in and fully assess the home and plan a good evacuation and fire drill training for the staff.” As part of the inspection process we undertook a tour of the building, and consulted several people who live in the home. We also consulted the manager and staff, including the handyman. We examined documentation in the home and questionnaire returns from staff, relatives, visiting professionals and people who live in the home. Examination of this documentation and consultations substantially confirm the statements as above. People who live in the home told us that they found the home spacious and comfortable, warm in the winter and as cool as possible in summer. The home is a superior property in extensive gardens, is clean and well maintained. People who live in the home benefit from the comparatively huge space the home offers, particularly in the communal rooms such as the large library, large lounge and sun room. Some of the bedrooms are particularly large. Sometimes this is because some people who live in the home have sole occupancy of a double room. People can bring into their bedrooms personal items, but also can bring in some items of furniture. If appropriate, some furniture can be brought into the public areas of the home. One person told us that she was very grateful to be allowed to bring in an item close to her heart but which was too big to suit her bedroom. This is now in a walkway upstairs. Very few, if any, care homes offer such a spacious home, which is well maintained. Over the last couple of years or so about £75k has been spent on improvements, most notably the complete renewal of the space-age kitchen. A new lift is about to be installed. The home benefits from having a gardener during the summer to look after the extensive grounds. A dedicated handyman is employed throughout the year with responsibilities for ongoing minor maintenance of the fabric of the building and some equipment. Primley House DS0000018413.V350857.R01.S.doc Version 5.2 Page 21 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, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home are cared for by well-trained and motivated staff in sufficient numbers to meet their needs. Recruitment processes protect vulnerable people who live there. EVIDENCE: The manager writes in the Annual Quality Assurance Assessment (AQAA) that: “We assess our staffing levels regularly against residents’ needs and higher dependency levels. We keep staffing rotas to show standards are kept. We provide training to all staff relevant to their role. NVQ is provided at different levels. Staff are encouraged to enrol and support is provided when required i.e. text books etc. We keep good documentation needed for staff files including Enhanced Disclosures and POVA Checks, proof of identity, two references with current employer history, application form, and contract of employment. We advertise vacancies locally and the Job Centre Website. We promote equal opportunities with the offer letter. For new employees we provide an Employee Handbook, a Health and Safety Handbook and General Social Care Council Code of Practise book. Stakeholder Pensions Scheme letter, confidentiality policy, job description, smoking policy statement, sickness policy letter (Bradford Scale) and policy statement on the recruitment of ex-offenders. Primley House DS0000018413.V350857.R01.S.doc Version 5.2 Page 22 We intend to make sure all staff are on top of training. Have more new staff and it is our aim to get them all involved with their NVQs. We intend to have our own occupational visiting therapist who would be able to help our clients improve their mobility therefore having a better quality of life. All paperwork for the above mentioned including a checklist, Higher Dependency scoring for residents, staff rotas which show more staff at peak times when residents are getting up bathing times, teatimes and going to bed. Our staff records show care staff providing care are over the age of 18 years and if left in charge over 21 years. The rotas show domestic staff are employed to maintain a clean environment, catering staff ensure standards relating to how food is kept the evidence show care assistants are not cleaning or cooking. Staff training is provided regularly for requirements and NVQ at different levels. We are also showing monthly supervisions and yearly appraisals on going. Updated polices and procedures are kept located for staff to read and use for their relevant role or training. Also COSHH data sheets are located for everyone to read. We provide the General Social Care Council Code of Practice in writing and audio.” As part of the inspection process we consulted several people who live in the home. We also consulted the manager and staff. We examined documentation in the home and questionnaire returns from staff, relatives, visiting professionals and people who live in the home. Examination of this documentation and consultations substantially confirm the statements as above. People who live in the home are well cared for by staff in sufficient numbers with sufficient competence, gleaned from both experience and training. The home uses a revised application form, which includes more detail in the previous employment history section, with reference to the Rehabilitation of Offenders Act, a declaration of no convictions, and undertakes Criminal Record Bureau checks. This latter check includes a check that the prospective employee is not on the Protection of Vulnerable Adults list of people unsuitable to work with vulnerable adults. Proper references are also taken up, which are now followed up with a telephone call, which is documented. The home has developed an interviewing check list and questionnaire to promote and document equality in job interviews. Job vacancies are discussed at Residents’ Meetings. The home is currently considering best practice regarding involving people who live in the home in the staff recruitment and selection process. The home is also considering how to provide any documentation for staff or people who live in the home in a range of formats. Staffing levels have been increased to cope with the increasing dependency of people who live in the home. The home’s rota shows an increase of staff during Primley House DS0000018413.V350857.R01.S.doc Version 5.2 Page 23 busy times. Of the twenty-six care staff, thirteen have achieved National Vocation Qualification NQV level 2 or higher, matching the 50 target. However, a further nine are working towards the qualification. When these have qualified the home will have 22 qualified staff, at 85 far exceeding the 50 target. Training has been given to senior members of staff in supervision and appraisal skills so that this can be delegated and kept updated. All senior staff have already attended, or are to attend an Advanced Medication course. The home has provided specialised training requested by staff including The Liverpool Care Pathway Care of the Dying. Staff consulted took pride in their work, and virtually all comments indicated this: “There is usually good interchange of information within the home”. Care plans are usually kept up to date, and relevant information passed on at handover”. “Usually the staff – service user ratio works well, the only time more staff could be of use is when something like a sickness and diarrhoea bug is about”. Virtually all staff comments regarding training and supervision were complimentary, including: “Primley has always provided opportunities for training and updating which is expensive. We are informed of dates and how we need to update, such as fire training. The manager is always available and always supportive and lets us know if anything applicable to our work comes up, such as a workshop I have just attended. This gave me new contacts, different ideas and slants on what I already do. Wide ranges of courses are offered to meet the needs of our individual residents”. “If any specialist training is needed, support is good from management to request these”. “NVQ training on request”. “Always plenty of training available, also encouraged to go on courses”. “Most discussions are held at appraisals, supervisions are held with seniors fairly regularly”. Primley House DS0000018413.V350857.R01.S.doc Version 5.2 Page 24 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, 32, 33, 35, 36, 37, 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. This is an excellent, well-managed home. People who live in the home benefit from the management approach of the home, which is run in the best interests of the people who live there. EVIDENCE: The manager writes in the Annual Quality Assurance Assessment (AQAA) that: “The Manager is qualified and competent to run the home on a day to day basis. She has gained NVQ Level 4 and the RMA. The assistant Manager also has gained Level 4 NVQ and is working towards her RMA. All Senior staff keep updated training relevant to their roles. We feel that residents live in an open Primley House DS0000018413.V350857.R01.S.doc Version 5.2 Page 25 and positive atmosphere it is very important to the Management and staff to provide high standards with the best possible outcomes. Policies and Procedures are kept up-to-date with new Regulations and Legislations. We make sure our quality assurance is implemented with outcomes displayed within the home. We make sure prospective residents receive a pre-assessment to make sure their needs can be meet. Visits are made to their homes or invited to Primley. Each new resident receives a handbook giving all aspects of information within the home. A contract of conditions is provided to be read before agreed. We have a Committee Meeting each month with a panel of members present, each have their own professional input to achieve what we do to benefit residents. Also to create a Business Plan for the coming month or year; making sure we meet our expected incomes and outgoings, expected profit or loss and cash flow forecast, wage increases etc. Monthly accounts are produced, onrolling yearly accounts are provided to look back on. A Manager’s Report is produced to give up to date information, which includes information of residents, staff, environment, training, entertainment and outgoings. Minutes are taken at the meeting for evidence to show our business and financial plans. Documentation is kept secure to protect residents and staff’s personal details. They are locked away for confidentiality reasons and only the persons who need to know have access other than themselves. Only the manager or assistant manager have access to residents’ spending money and a clear account is kept for each resident who requests that their money is secure in the safe. We keep a safe working environment. Keeping maintenance up to date. Keeping risk assessments recorded. Records of all accidents, injuries and illnesses and report to the appropriate persons. The building is kept in good order. We have a full time maintenance man for this reason.” As part of the inspection process we consulted several people who live in the home. We also consulted the manager and staff. We examined documentation in the home and questionnaire returns from staff, relatives, visiting professionals and people who live in the home. Examination of this documentation and consultations substantially confirm the statements as above. The manager is well qualified and experienced and is well supported by the assistant manager, administrative officer, chair of the management committee, and the rest of the particularly able committee. Considerable work has been undertaken over the past couple of years or so to enhance the fabric of the building and enhance the facilities for people who live in the home, and more is planned, such as renewal of the lift. The financial interests of people who live in the home are safeguarded. They are encouraged and enabled to maintain their own benefit book and handle their own financial affairs if appropriate. Several people who live in the home Primley House DS0000018413.V350857.R01.S.doc Version 5.2 Page 26 are subject to Power of Attorney. The manager is not appointee for anyone who lives in the home. The manager is becoming more acquainted with the new Mental Capacity Act as it may affect people who live in this home. The health, safety and welfare of people who live in the home are promoted and protected by adherence to recognised health and safety policies and practices including fire precautions. The home works in partnership with local health and social care facilities such as General Practitioners, District Nurses, Care Managers, a Speech and Language Therapist and the like. The home consults with external statutory agencies and other professionals as necessary from time to time, such as Environmental Health, Fire and Rescue Service, Health Protection Agency and the like. But this home goes that extra mile by employing its own Activities Organiser, Gardner, Handyman and Administrative Officer and intends to employ its own Occupational Therapist to assist people with mobility and its own Fire Officer to enhance fire precautions in the home. All these measures enhance the safety and wellbeing of people who live in the home. Staff and Residents meetings are held regularly to show an open and transparent approach. The manager and assistant manager appraisal shows a clear sense of direction for leadership. A visiting Health professional comments that Primley House is: “A very well run home. Very organised, clean and tidy, good team work. On each visit staff are very friendly and helpful. A lively atmosphere. Lots of activities going on to stimulate clients. Well organised home.” We shall let a relative sum up our judgement that: “The overall care is excellent”. Primley House DS0000018413.V350857.R01.S.doc Version 5.2 Page 27 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 4 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 4 4 3 3 4 4 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 4 3 4 X 3 3 X 4 Primley House DS0000018413.V350857.R01.S.doc Version 5.2 Page 28 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. Refer to Standard Good Practice Recommendations Primley House DS0000018413.V350857.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Region Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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