Inspection on 22/05/07 for Primley View Nursing Home

This inspection was carried out on 22nd May 2007.

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 View Nursing Home 13/09/06

Primley View Nursing Home 21/03/06

Primley View Nursing Home 07/10/05

Primley View Nursing Home 26/11/04

Primley View Nursing Home 20/04/04

Primley View Nursing Home 12/11/03

Primley View Nursing Home 06/06/03

Primley View Nursing Home 28/05/02

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

CARE HOMES FOR OLDER PEOPLE Primley View Nursing Home Primley View 25 Primley Park Paignton Devon TQ3 3JW Lead Inspector Mandy Norton Unannounced Inspection 22nd May 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 View Nursing Home DS0000028756.V335853.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 View Nursing Home DS0000028756.V335853.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Primley View Nursing Home Address Primley View 25 Primley Park Paignton Devon TQ3 3JW 01803 559229 01803 559229 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 Susan Mary Wiltshire Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (3), Physical disability (30), Physical disability of places over 65 years of age (30) Primley View Nursing Home DS0000028756.V335853.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Registered for max PD 30 Registered for max PD(E) 30 service usres over the age of 65 Registered for max OP 3 Date of last inspection 13th September 2006 Brief Description of the Service: Primley View Nursing Home is built in an elevated position overlooking the seaside town of Paignton. It offers panoramic views of Torbay from Thatcher Rock to Berry Head. It caters for elderly people who have a physical illness or disability that need respite or full time nursing care. There is a trained nurse on duty 24 hours a day. There are three lounges and 27 bedrooms, two of which are double bedrooms and seven that have en suite facilities. Several of the bedrooms enjoy sea views. A shaft lift goes to each floor that the Service Users are accommodated on. This home is comfortably furnished throughout creating a warm, friendly and relaxed environment. All of the rooms contain a nurse call bell system and television point, some have their own telephone sockets. There is a small patio area to the rear of the building that is accessible to wheelchair users. Relatives and friends may visit at any reasonable time. The current fees range from £475 to £550 (information taken from the pre inspection questionnaire received on 25.04.07)). All people living in the home are issued with a contract, some detail the funded nursing care contribution, some do not but all have the fee charged included in them. The manager was advised to place a copy of the last inspection report near to the main entrance and to ensure that the Service Users Guide /Statement of Purpose includes information about how people who cannot visit the home or have access to the internet can access the report. It is also recommended that a copy of the most recent Service Users Guide/Statement of Purpose should also be available near the entrance and that all people living in the home or their representatives have access to the guide. Primley View Nursing Home DS0000028756.V335853.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place from 10.30 am until 3.40 pm and was conducted with the manager, with input from the quality assurance manager. A tour of the home was carried out. (Some Service Users seen were not always able to fully express themselves fully or comment on the care they received). This report also contains views from 8 completed care workers surveys and 6 relatives surveys reflected throughout, information taken from the completed pre inspection questionnaire and discussion with staff on the day of the inspection. There were 25 people living in the home at the time of the inspection, 4 of whom had been admitted under the local CARRIE scheme (emergency respite admission scheme). What the service does well: What has improved since the last inspection? The home is undergoing refurbishment and redecoration. The carpet has been renewed throughout the old part of the house, the corridors have been wallpapered and several people’s rooms have been redecorated. This has made the older part of the house much brighter. Primley View Nursing Home DS0000028756.V335853.R01.S.doc Version 5.2 Page 6 A new kitchen has been installed. A new drugs trolley has been purchased in order to make the transport of medicines around the home easier. The owner has agreed to increase staffing levels in the afternoon in order that the workload can be managed and more individual attention can be paid to people’s social needs as well as their physical needs. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Primley View Nursing Home DS0000028756.V335853.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 View Nursing Home DS0000028756.V335853.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service or are prospective Service Users have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. The home is not registered to provide intermediate care. EVIDENCE: The manager visits prospective long term Service Users in their current setting if at all possible and completes a client detail sheet and nursing model sheet Primley View Nursing Home DS0000028756.V335853.R01.S.doc Version 5.2 Page 9 (activities of daily living) during this visit taking information supplied by the Service User, family or health care professionals looking after the person. The home also has regular admissions via the local CARRIE team (emergency admission for short term/respite care), they have 4 beds ‘blocked’ for this scheme and sometimes beds are ‘spot purchased’ if all the designated beds are full. Different documentation is used when these people are admitted to the home and the initial assessment of need is supported by the care plan completed by the care manager arranging the admission. In either case the pre admission information forms the basis of the care plan. The manager was advised to have at least the last inspection report on display near to the main entrance and to ensure the Statement of Purpose has information about how to access the inspection reports if people cannot visit the home or do not have access to the internet. Contracts are issued to all Service Users once they have moved in whether they are privately or publicly funded. The contracts seen included the fee level to be charged. Of the three contracts examined one (1) had the nursing care contribution detailed on it and the other two (2) did not. The cost of the ‘small administrative charge’ made for invoicing people for their expenditure such as hairdressing, chiropody and newspapers was not detailed. Primley View Nursing Home DS0000028756.V335853.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. 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. The manager promotes and maintains peoples health and ensures access to health care services to meet assessed needs. The homes medication systems generally protect the welfare of Service Users. People are treated with respect and their right to privacy is upheld. EVIDENCE: Care plans examined (3) had all the required information in them (skin integrity, moving and handling, safety - including risk of falls, use of bed rails risk assessments and nutritional screening). None had been signed by a Primley View Nursing Home DS0000028756.V335853.R01.S.doc Version 5.2 Page 11 relative to say that they had discussed and agreed the content of the care plan. The care plans included risk assessments for bed rails that are in use, these had had been reviewed. The manager was advised that all forms of restraint should have a risk assessment carried out, which should be included in the care plan. Professional visits from chiropody services, speech and language therapy (SALT), tissue viability service and GP’s were all documented in the care plans. The care plans examined had information about hobbies and pastimes included in them. T The format of the care plans is being updated to ensure the content reflects accurately the individual needs of each person. The care plans for the people admitted under the CARRIE scheme are slightly different and are used on a daily basis by the team that visit the Service User to ensure the information about the person is up to date and accurate. Four (4) of the six (6) completed relatives surveys indicated that the home usually meets the needs of their relative and two (2) indicated that they always meet their needs. Six (6) of the eight (8) completed staff surveys indicated that staff are not asked to look after people outside their area of expertise and 2 indicated that they were expected to. The medication system is generally well managed. The deputy checks stock and orders required medicines on a regular basis. A new drugs trolley has been purchased since the last inspection to ensure correct storage and administration procedures are carried out. Disposal of unused/ out of date medication is safe, well recorded and removed by a licensed contractor. During a tour of the home some tubs and tubes of cream had no opening date on them, had no prescription label on them (so it could not be identified if these items had been dispensed for the person using them) and in one case a tub of cream was in a bathroom with no individual name on it meaning it could be being used for more than one person. The matron immediately removed these items and told the inspector that staff would be reminded that this is not good practice. (The manager has a history of compliance with recommendations made during inspections). Appropriate interactions between staff, people living in the home and visitors was heard during the inspection. People were heard knocking on doors before entering rooms. Service User spoken to said that they have a choice of where to spend their day and what time they get up. One commented that she is asked what she would like to wear, but is happy for the carers to choose. A GP was visiting during the inspection and was able to consult with the Service User in their room in private. Primley View Nursing Home DS0000028756.V335853.R01.S.doc Version 5.2 Page 12 Primley View Nursing Home DS0000028756.V335853.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Effort is made by the home to provide an activities programme and social interaction/stimulation for people who live in the home. People are able to maintain contact with family and friends and exercise choice and control over their lives. People receive a wholesome appealing diet and are not rushed. EVIDENCE: The care plans examined had information about hobbies and pastimes included in them. The manager said that the activities co-ordinator visits twice a week for 3 hours each time and does a variety of things with people living in the home. Primley View Nursing Home DS0000028756.V335853.R01.S.doc Version 5.2 Page 14 There is also an organised singing session once a month and visits from the local church regularly. She said that sometimes they are able to take Service Users out in a taxi, in small groups, to see the Christmas lights for example. There was no activities programme displayed within the home on the day of the inspection. The manager said it will be displayed again once the decorating has been finished (there was painting and maintenance ongoing throughout the inspection). The activities book was examined, this has the names of people attending the sessions and what they did, and it was found to contain information about what had been done and by whom. Some of the completed staff surveys and relatives surveys indicated that it would be nice to have more time to spend with people living in the home individually to read or do crosswords with them for example. The inspector was informed during the inspection that this situation had been highlighted as a concern by the manager and as a result the provider is going to increase the staffing level in the afternoons in the near future. A new kitchen has been installed and was being cleaned ready for use during the inspection. The main meals have been provided by a local hotel during the work and other meals and drinks have been made using the small kitchenette in the new extension. People have been kept informed of the process throughout. The cook was in the kitchen and said she was using the Safer Food Better Business system prior to the refit and would be updating and using it once the kitchen is in use again. Primley View Nursing Home DS0000028756.V335853.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): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the home and their relatives/friends generally know how to make a formal complaint. People are safe living in this home. EVIDENCE: The pre inspection questionnaire stated that there have been no complaints since the last inspection and no referrals to adult protection services. There has been one anonymous concern raised with CSCI since the last inspection. As a result of this a random inspection was carried out during an early evening to assess whether people were being put to bed early. No evidence of this was found to support this concern. The complaints procedure is displayed within the home and is in the Statement of Purpose, which the manager said, is available to all people admitted to the home and/or their relatives/representatives. Two (2) of the six (6) completed relatives surveys indicated that they knew how to make a formal complaint, three (3) said they did not know how to and Primley View Nursing Home DS0000028756.V335853.R01.S.doc Version 5.2 Page 16 one (1) did not answer the question. Most of the completed surveys and people living in the home spoken to said the manager and staff are very approachable and concerns can be discussed with them at any time. Seven (7) out of eight (8) completed staff surveys indicate that they are aware of adult protection procedures Primley View Nursing Home DS0000028756.V335853.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): 19, 20, 22, 23, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is safe and well maintained and clean and hygienic ensuring the people living in the home live in a satisfactory environment. EVIDENCE: Refurbishment and redecoration of the home are currently ongoing. There has been a new kitchen installed, new carpet throughout the old part of the home (although where there is heavy ‘traffic’ it already looks marked and worn, the owner is aware of this). Primley View Nursing Home DS0000028756.V335853.R01.S.doc Version 5.2 Page 18 The entrance hall and corridors in the old part of the building have been redecorated and the office was being painted on the day of the inspection. The manager said that a lot of the individual rooms are also being decorated. The manager said that people living in the home and their relatives are being kept informed of what is happening and any disruptions they may be faced with. She said people have viewed the ongoing work positively. There are 3 lounges within the home, one on each floor and one in the extension. They are used by a number of the Service Users. There is no dining room so people often have their meals in one of the lounges or in their room. People’s rooms contain personal items including furniture, ornaments and pictures that reflect their personality and interests. Most of the radiators in the old part of the home do not have covers on them. The manager said that the ones in the corridors are never switched on and the maintenance records examined included a risk assessment of all radiators throughout the home. The risk assessment should be updated every-time a new person moves into a room. Lifting and handling equipment and wheelchairs were stored appropriately when not in use. A variety of equipment examined during a tour of the home had recent servicing dates on them. All of the homes equipment is maintained by the company’s maintenance team, a variety of records were seen to support this. A local handyman is employed to carry out day to day maintenance such as changing light bulbs. The water temperature was checked in a number of taps in the old part of the home and they were found to be very hot. The maintenance manager was in the home at the time and he altered the temperature of the thermostat to reduce the temperature (this was newly fitted as a problem was noted with the water the previous week). The water was still hot a short while later but the hot water had not yet been ‘run off’. A signed description of what was done on the day of the inspection to reduce the temperatures was given to the inspector with verbal confirmation that all outlets will be tested in the near future. There is a call bell system fitted throughout the home. The bell in the old part of the house is loud but the manager said that it can be heard wherever staff are working and it can then be attended to. The laundry is a suitable size for the amount of washing the home produces and although it is next to the kitchen and dry food - store this is not a problem. Clean laundry was being delivered to peoples’ rooms during the inspection. Primley View Nursing Home DS0000028756.V335853.R01.S.doc Version 5.2 Page 19 The home was clean and hygienic. All hazardous chemicals were stored appropriately and the chemicals store cupboard was locked. There are a variety of hand washing facilities prominently placed around the home. Although soap dispensers are fitted next to all sinks used bars of soap were also placed on a number of sinks and baths. The manager was advised that these should be removed as it is not good practice in infection control. This was done immediately. Primley View Nursing Home DS0000028756.V335853.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of staff with generally appropriate skills and knowledge to meet the needs of the people living at the home. The homes recruitment procedures protect people living at the home from being placed at risk of harm or abuse EVIDENCE: Duty rotas supplied with the pre inspection questionnaire indicate that the manager works full time, this includes some weekends. She is supported by trained nurses and carers and catering, domestic and maintenance staff. For 25 Service Users (4 of whom are under the CARRIE service) there is a trained nurse on duty 24 hours a day supported by 5 carers in the morning and 3 carers in the afternoon and early evening. Overnight the nurse is supported by 2 carers. The manager has 2 days a week supernumerary so that she can manage the administrative tasks that are part of her role. Primley View Nursing Home DS0000028756.V335853.R01.S.doc Version 5.2 Page 21 Some completed relatives and staff surveys indicated that there was not enough time for individual activities with people living in the home such as reading a newspaper or simply talking. Some completed staff surveys also indicated that the CARRIE clients seem to get more attention than the long stay people and that more staff would help to adjust the balance. The manager has fed these concerns to the provider who has agreed to increase staffing levels in the afternoons in the near future. Seven (7) of the eight (8) completed staff surveys confirmed that funding and time are provided to receive relevant training. Some of the completed staff and relatives surveys indicated that staff are not confident in providing care to those people living in the home that suffer from mild confusion and/or dementia. The manager said that training could be provided by staff from their sister home nearby who are registered and trained to look after people with dementia. The manager said that some senior carers have been trained to manage PEG feeds (tube feeding into the stomach). It was recommended any training of this nature should be documented to detail exactly what the carer has been taught and by whom and this should be reviewed as necessary. Two (2) staff files were examined – they had all of the required documents in them including 2 written references, a CRB check, application form, contract of employment and job description. The staff files are stored securely. The file also included training certificates which confirmed that a variety of training is undertaken by staff and one had supervision records. It is clear from talking to the manager that she does supervision sessions with the staff often on an unplanned basis. This is supported by information on the completed staff surveys. It is advised that she has a system for documenting these sessions so that quality assurance audits can identify when sessions have taken place. Primley View Nursing Home DS0000028756.V335853.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by an experienced Registered Nurse. There is a formal quality assurance system in place and the company have appointed a quality assurance manager to assist all of their homes in the quality assurance process. Personal money held by Optima Care Partnership on behalf of Service Users is managed appropriately. The registered provider shows a responsible attitude toward promoting and protecting the health, safety and welfare of Service Users. Primley View Nursing Home DS0000028756.V335853.R01.S.doc Version 5.2 Page 23 EVIDENCE: The current manager has several years experience of managing the home and is competent in her role. A number of the completed care workers surveys indicate that the home is well run and the manager is approachable. A completed relatives survey commented that ‘the matron is wonderful and knows all her residents and meets their needs’. The manager said she doesn’t hold formal staff meetings but uses the staff handover times to update staff on any changes or pass over important information. This is supported by completed staff surveys as many of them commented on the good communication within the home. She said she has an open door policy and due to a low staff turnover she knows her staff well and often recognises when there may be any problems or worries. The company have recently appointed a quality assurance manager who was available during majority of the inspection. He has recently carried out a full audit of the home the results of which are being discussed with the manager and any changes required being implemented as an ongoing process. The manager will continue to periodically send out satisfaction surveys to relatives and representatives of the people living in the home to gain their views of the service and also to people living in the home who can make their wishes known. The company’s maintenance team visit the home on a regular basis to carry out portable electrical testing (PAT), equipment servicing (e.g. mattresses, hoists etc.), water temperature checks and other general maintenance. A local handyman is available for ongoing maintenance such as changing light bulbs and other small tasks that may have been entered in the maintenance book. Most of the radiators in the old part of the home do not have covers on them. The manager said that the ones in the corridors are never switched on and the maintenance records examined included a risk assessment of all radiators throughout the home. The risk assessment should be updated every-time a new person moves into a room. The water temperature was checked in a number of taps in the old part of the home and they were found to be very hot. The maintenance manager was in the home at the time and he altered the temperature of the thermostat to reduce the temperature (this was newly fitted as a problem was noted with the water the previous week). The water was still hot a short while later but the Primley View Nursing Home DS0000028756.V335853.R01.S.doc Version 5.2 Page 24 hot water had not yet been ‘run off’. A signed description of what was done on the day of the inspection to reduce the temperatures was given to the inspector with verbal confirmation that all outlets will continue to be tested regularly. During discussion with the manager about management of pregnant staff it was clear that all of the correct advice and support is being given, however it was discovered that the company do not have a formal policy or risk assessment guidance about pregnancy and its implications. A company representative said that this would be rectified and a policy would be put in place. The manager explained that no Service User money is held on the premises as the head office deal with income and expenditure. Petty cash is held on the premises if Service Users need any money quickly. The fire log - book and accident books examined and were up to date and completed as required. Primley View Nursing Home DS0000028756.V335853.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 X 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 2 Primley View Nursing Home DS0000028756.V335853.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations An up to date Service Users Guide/Statement of Purpose should be placed near the front entrance to ensure all of the people that live in the home and visit have access to it. The provider should ensure that any fees charged and their breakdown are clearly identified in the individual contacts. It is recommended that all pots of creams and lotions should have a pharmacy label with the Service Users name on them and a date of opening clearly written on them. Bars of soap should not be placed on bathroom sinks or baths where there is a soap dispenser available. If they are a Service Users personal bar of soap then it should be taken back to their room with them once they have finished in the bathroom Any training that is provided to care staff by nursing staff should be documented to indicate to what level of DS0000028756.V335853.R01.S.doc Version 5.2 Page 27 2. 3. 4. OP2 OP9 OP26 5. OP30 Primley View Nursing Home 6. OP38 7. OP38 competence they have been trained. This document should be signed by the person doing the training and the level of competence reviewed on a regular basis. Water temperatures should be closely monitored following the fitting of a new thermostat to ensure the water is being delivered at the tap at around 43 degrees centigrade. Optima care Partnership should develop a pregnancy policy and risk assessment for use when a staff member is pregnant. Primley View Nursing Home DS0000028756.V335853.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 View Nursing Home DS0000028756.V335853.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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