CARE HOMES FOR OLDER PEOPLE
Primrose Bank 153 Breck Road Poulton Le Fylde Lancashire FY6 7HJ Lead Inspector
Mrs Gwen Miller Unannounced Inspection 24th January 2006 13:30 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 Primrose Bank DS0000063466.V280073.R01.S.doc Version 5.1 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. Primrose Bank DS0000063466.V280073.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Primrose Bank Address 153 Breck Road Poulton Le Fylde Lancashire FY6 7HJ 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) 01253 884488 Primrose Bank Limited Mrs Jacqueline Ellen Moore Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Primrose Bank DS0000063466.V280073.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 1st August 2005 Date of last inspection Brief Description of the Service: Primrose Bank is a residential home situated on Breck Road in Poulton-leFylde. It is situated in its own grounds with a garden area to the front and a small parking area at the rear. The village shops, facilities and the train station are in close proximity. The home accommodates 28 residents in single rooms, six of which have en-suite facilities. There is a stair lift to the rear of the home. All bedrooms are personalised and furnished to a good standard. Some bedrooms are smaller than the minimum standard of 10 sq meters. There are three lounges and a large dining area, all of which are furnished to a good standard. The home is non-smoking throughout. There are adequate toilets and bathing facilities. The home is kept very clean and hygienic. There is a commitment to staff training within the home. The registered providers are Mrs J Moore and Mrs E Abbas who manage the home on a day-to-day basis. Primrose Bank DS0000063466.V280073.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place with Mrs Abbas, the proprietor. The inspector spoke with residents and staff members on duty. . Case tracking (whereby the inspector focuses on a small number of residents and examines their care, from admission to the present time) , was carried out. Part of the inspection was spent looking at daily notes and information about the home and residents. Time was spent observing the workings of the home and how staff members supported residents. What the service does well: What has improved since the last inspection? What they could do better:
Staff files still need to include employment histories of prospective staff members, so that the manager knows full details of a person before offering them employment at the home. The home was required to do this following the previous inspection on 1st August 2005, but has not done so. Primrose Bank DS0000063466.V280073.R01.S.doc Version 5.1 Page 6 The home must ensure that new staff members have up to date Criminal Records Bureau (CRB) and Protection of Vulnerable Adult (POVA) clearances in keeping with CRB guidance, prior to commencing their employment. 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. Primrose Bank DS0000063466.V280073.R01.S.doc Version 5.1 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 Primrose Bank DS0000063466.V280073.R01.S.doc Version 5.1 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): These core standards were assessed and met on the previous inspection. EVIDENCE: Primrose Bank DS0000063466.V280073.R01.S.doc Version 5.1 Page 9 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): 8 The health needs of residents are well met with evidence of good multi disciplinary working taking place on a regular basis. EVIDENCE: From information in the home’ s pre inspection questionnaire and discussion with residents and observation of care files, it was clear that residents receive the same health services as others living in the community. Visits by G.P. s, district nurses, dentist, opticians and chiropody were recorded on resident’s files. Specialist advice from geriatricians, continence advisors and community psychiatric nurses, is sought when necessary, to meet the needs of the residents. A daily report and programme of personal care is kept for each resident and used to alert staff coming on duty to be aware of any changes in resident’s health or well being. Primrose Bank DS0000063466.V280073.R01.S.doc Version 5.1 Page 10 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): 14 The systems for resident consultation are good and evidence indicates that resident’s views are both sought and acted upon. EVIDENCE: Residents are asked to make choices in what to eat, when to rise and retire, how to spend their time, how to furnish their room, how they wish to be addressed, who they wish to keep company with, who they want to manage their affairs (if they do not want to manage themselves). They are also asked if they wish to manage their own medication and given a choice of locking their bedroom doors. All residents spoken with said they chose what to do with their time, although they were encouraged to join in activities in a communal setting, their choice to remain in their own rooms or go out into the community, was acknowledged. Primrose Bank DS0000063466.V280073.R01.S.doc Version 5.1 Page 11 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): These core standards were assessed and met on the previous inspection, since then there have been no complaints received at the Commission for Social Care Inspection. EVIDENCE: Primrose Bank DS0000063466.V280073.R01.S.doc Version 5.1 Page 12 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): These core standards were assessed and met on the previous inspection. EVIDENCE: Primrose Bank DS0000063466.V280073.R01.S.doc Version 5.1 Page 13 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): 29 & 30 The policies and procedures for the recruitment of staff must be extended to ensure the protection of residents. Staff training is ongoing to further ensure that staff can meet the changing needs of the people living at Primrose Bank. EVIDENCE: Staff files still need to include details of the work histories of prospective staff including any gaps in employment so that the manager knows full details of a person before offering them employment at the home. This was a requirement following the previous inspection on 1st August 2005 and has not been carried out. The newest staff member had produced a Criminal Records Bureau clearance from her previous job in 2003, such clearances are not portable from one post to another. The home must ensure that new staff members have up to date Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) clearances, in keeping with CRB guidance, prior to commencing their employment. An immediate requirement notice was issued to the home. Records show that many staff are continuing with National Vocation Training (NVQ), the home aims to meet the target figure of 50 staff trained to level 2 NVQ this year. All residents spoke very well of the staff. Comments included “they can’t do enough for you” and “they are always so helpful”.
Primrose Bank DS0000063466.V280073.R01.S.doc Version 5.1 Page 14 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): 33,35,38 The home reviews aspects of its performance through consultation, which includes seeking the views of residents, thereby ensuring the home is run in their best interests. Good procedures are in place to safeguard the financial interest of residents. EVIDENCE: Comments are sought from relative and residents through a ‘client review’ questionnaire. Topics include, bathing arrangements, meal standards, contentment with personal rooms, medication arrangements and activities. Residents are also asked to add any further comments so that their daily living patterns can be altered or improved. Residents are encouraged to handle their own finances or elect family or a solicitor to do this for them. The pre inspection questionnaire received prior to
Primrose Bank DS0000063466.V280073.R01.S.doc Version 5.1 Page 15 the previous inspection, showed that three residents had chosen to handle their own affairs. Primrose Bank has comprehensive Health & Safety Policies, knowledge of these forms part of staff induction. Staff undertake mandatory training in Moving & Handling, Fire, Control of Hazardous Substances, First Aid, Infection Control and Food Hygiene. Fire drills are carried out, maintenance of equipment is completed regularly and relevant certificates are held at the home. Primrose Bank DS0000063466.V280073.R01.S.doc Version 5.1 Page 16 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 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 x 3 x x 3 Primrose Bank DS0000063466.V280073.R01.S.doc Version 5.1 Page 17 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 19 Requirement Personnel records must be extended, to include employment histories. (Previous timescale of 01/09/05 not met) New staff must have satisfactory police checks and Protection of Vulnerable Adults check. Timescale for action 24/01/06 2. OP29 19 24/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP28 Good Practice Recommendations 50 of care staff should achieve NVQ level 2 Primrose Bank DS0000063466.V280073.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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