Inspection on 21/09/06 for Primley House

This inspection was carried out on 21st September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 20/12/07

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 Housing Association Ltd Primley House Totnes Road Paignton Devon TQ3 3SB Lead Inspector Peter Wood Unannounced Inspection 21 September and 20 November 2006 03:00 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 Housing Association Ltd DS0000018413.V313716.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 Housing Association Ltd DS0000018413.V313716.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Primley Housing Association Ltd Address Primley House Totnes Road Paignton Devon TQ3 3SB 01803 558867 01803 558867 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) 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 Housing Association Ltd DS0000018413.V313716.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 05/10/05 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 disabled ramp to the side. 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 disabled residents toilets and a shower room. There are 8 single en-suite bedrooms on the ground floor, 3 of which have en-suite baths. There are stairs with a shaft lift to the first floor which has a further twenty-two single ensuite 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 residents and visitors to refer to. Primley Housing Association Ltd DS0000018413.V313716.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 afternoon in September 2006 and a further day in November 2006. The focus of this inspection was to inspect all key standards and to seek the views of residents, staff, relatives and professional visitors to the home, the latter mainly using comment cards and survey forms. At the time of writing this report nine staff returned the “Care Workers Survey” form. No “General Practitioners Comments Cards” were returned. No “Health and Social Care Professionals in Contact with the Care Home” returned a form. Two “Relatives/ Visitors Comment Cards” were returned. Only two “Have your say about Primley House” survey forms were received from resident, but several residents who were home at the time of the inspection were consulted. Some relatives who happened to be visiting at the time were also consulted, as were staff while they were undertaking their duties. Considerable time was spent with the Registered Manager and her deputy 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 PreInspection Questionnaire was also examined. What the service does well: Quality in all outcome areas is good. This judgement has been made using available evidence including a visit to this service and takes into account the views and experiences of people using the service. Assessments undertaken prior to admission allow prospective residents and their relatives to be confident that their needs can be met. Prospective residents and their relatives are encouraged to visit prior to admission. The home does not offer intermediate care. Residents’ health, personal and social care needs are met and they are treated respectfully. The home’s practices relating to medication administration protect the residents from risk. The home provides varied social activities. Residents 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. Complaints and suggestions from residents, relatives or other visitors to the home are treated seriously. Residents are listened to and issues resolved promptly. Primley Housing Association Ltd DS0000018413.V313716.R01.S.doc Version 5.2 Page 6 The residents live in a pleasant, well-maintained comfortable home that provides sufficient facilities to meet their needs. However, the water temperature to two baths need to be controlled to prevent scalds. Residents are cared for by well-trained and motivated staff in sufficient numbers to meet the needs of those currently living in the home. Recruitment processes protect vulnerable residents. This is a good, well-managed home. Residents benefit from the management approach of the home, which is run in the best interests of the residents. However, the thermostatic valves to two baths need attention to prevent scalds. What has improved since the last inspection? 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. Primley Housing Association Ltd DS0000018413.V313716.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Primley Housing Association Ltd DS0000018413.V313716.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service and takes into account the views and experiences of people using the service. Assessments undertaken prior to admission allow prospective residents and their relatives to be confident that their needs can be met. Prospective residents and their relatives are encouraged to visit prior to admission. The home does not offer intermediate care. EVIDENCE: The home receives assessment documentation from Social Services to identify residents’ needs prior to admission. This is invariably followed up by the manager or her deputy undertaking their own home visit. These processes help to ensure that the home is able to meet the needs of the prospective resident. Residents 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. Primley Housing Association Ltd DS0000018413.V313716.R01.S.doc Version 5.2 Page 9 Many current residents had been to visit, stay for lunch or over a day before making application to move to this home. The home does not offer intermediate care. Primley Housing Association Ltd DS0000018413.V313716.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service and takes into account the views and experiences of people using the service. Residents’ health, personal and social care needs are met and they are treated respectfully. The home’s practices relating to medication administration protect the residents from risk. EVIDENCE: Most residents 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. However, while their health and personal needs are met, some residents commented that owing to the increasing dependency of many fellow residents, staff were too busy to spend time talking to them or attending to them in such areas as cutting their nails. Detailed assessments were recorded upon admission and on significant change. These described the residents’ care needs which generate the individual care plans. These plans are somewhat duplicated, for the separate Primley Housing Association Ltd DS0000018413.V313716.R01.S.doc Version 5.2 Page 11 use of seniors and care staff. This system works well in this home, but a reduction of duplication of documentation is recommended to avoid unnecessary effort and potential errors. Medication administration records were well maintained. Medication was stored safely, including those in the rooms of residents who self-medicate. This home tries very hard indeed to involve all staff, relatives but especially residents in as many areas of running the home as possible. Residents are encouraged to exercise as much choice as possible. Residents confirmed this was the case. Residents’ meeting are regularly held. Staff were seen to respect residents’ privacy and dignity in the way they addressed and spoke about residents. They knocked and waited for a response prior to entering residents’ bedrooms, and sought their permission before going into their rooms on other occasions. Primley Housing Association Ltd DS0000018413.V313716.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service and takes into account the views and experiences of people using the service. The home provides varied social activities. Residents 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. EVIDENCE: Many residents at 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. Most of these are planned in advance with the residents. A notice board provides information about the activities offered and other matters of interest to residents. Residents 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. Primley Housing Association Ltd DS0000018413.V313716.R01.S.doc Version 5.2 Page 13 Residents are encouraged to do as much for themselves as possible, rather than becoming dependent on staff. For example, residents are encouraged to do their own shopping, and a free bus to the shops is provided twice a week Residents said that the food was plentiful and mostly very good. The dedicated chef is knowledgeable about nutrition and resident’s needs and preferences. Most residents 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 were available at all times to residents and their visitors: water fountains provide excellent cool water whilst a coffee percolator in the front hall is well used. Primley Housing Association Ltd DS0000018413.V313716.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service and takes into account the views and experiences of people using the service. Complaints and suggestions from residents, relatives or other visitors to the home are treated seriously. Residents are listened to and issues resolved promptly. EVIDENCE: The home has a complaints procedure available to all residents and visitors to the home and detailed in the home’s Service User Guide. This includes a book for recording complaints, but this is rarely used. Residents 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 assist residents recognise members of the committee who visit regularly, and the chair visits several times each week. Photographs of all staff members are kept in a book in the hall to refresh residents’ memories of the names of staff. Staff have received training in issues relating to abuse and the protection of vulnerable adults, and the home’s whistleblowing policy has been used. This indicates that staff are confident in raising any concerns they may have about practices in the home. Primley Housing Association Ltd DS0000018413.V313716.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service and takes into account the views and experiences of people using the service. The residents live in a pleasant, well-maintained comfortable home that provides sufficient facilities to meet their needs. However, the water temperature to two baths need to be controlled to prevent scalds. EVIDENCE: Residents said that they found the home spacious and comfortable, warm in the winter and as cool as possible in summer heat. The home is a superior property in extensive gardens, is clean and well maintained. Over the past year about £75k has been spent on improvements, most notably the complete renewal of the space-age kitchen. The home benefits from having a dedicated handyman with responsibilities for ongoing minor maintenance of the fabric of the building and some equipment. While the home’s policy is for staff to Primley Housing Association Ltd DS0000018413.V313716.R01.S.doc Version 5.2 Page 16 supervise residents’ bathing, the hot water to two of the baths was well above the recommended temperature. The thermostatic valves need urgent attention to ensure that residents cannot scald themselves, though in practice it is recognised that this would be unlikely. Primley Housing Association Ltd DS0000018413.V313716.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service and takes into account the views and experiences of people using the service. Residents are cared for by well-trained and motivated staff in sufficient numbers to meet the needs of those currently living in the home. Recruitment processes protect vulnerable residents. EVIDENCE: Residents are well cared for by staff in sufficient numbers with sufficient competence. The home uses a proper application form 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. Comments such as: “The staff are very kind; nothing is too much trouble”, “Staff cannot do too much for you here” were repeated several times by residents. Staffing levels have been increased to cope with the increasing dependency of residents, seven of whom have high needs, seven with medium needs, though Primley Housing Association Ltd DS0000018413.V313716.R01.S.doc Version 5.2 Page 18 still the vast majority – twenty-one – have low needs. Of the twenty-two care staff, sixteen have NQV level 2 or higher, at 73 exceeding the 50 target. Primley Housing Association Ltd DS0000018413.V313716.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service and takes into account the views and experiences of people using the service. This is a good, well-managed home. Residents benefit from the management approach of the home, which is run in the best interests of the residents. However, the thermostatic valves to two baths need attention to prevent scalds. EVIDENCE: The manager is well qualified and is well supported by the deputy and the chair of the management committee, and the rest of the particularly able committee. Considerable work has been undertaken over the past year or so to enhance the fabric of the building and enhance the facilities for residents. Primley Housing Association Ltd DS0000018413.V313716.R01.S.doc Version 5.2 Page 20 Residents’ financial interests are safeguarded. One resident maintains their own benefit book, while eleven residents handle their own financial affairs. Twenty-one residents are subject to Power of Attorney. The manager is not appointee for any resident. The health, safety and welfare of residents are promoted and protected by adherence to recognised health and safety policies and practices including fire precautions. However, the thermostatic valves to two baths need attention to ensure that residents are not scalded, however remote the likelihood. Primley Housing Association Ltd DS0000018413.V313716.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Primley Housing Association Ltd DS0000018413.V313716.R01.S.doc Version 5.2 Page 22 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. 1. Standard OP25 OP38 Regulation Reg 13 (4) (a) Requirement The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. (This relates to the hot water serving two baths which needs thermostatic control to prevent scalds). Timescale for action 20/01/07 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 A reduction of duplication of documentation, such as service user plans, is recommended to avoid unnecessary effort and potential errors. Primley Housing Association Ltd DS0000018413.V313716.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Primley Housing Association Ltd DS0000018413.V313716.R01.S.doc Version 5.2 Page 24 - 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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