Inspection on 17/05/05 for Primrose Court

This inspection was carried out on 17th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Primrose Court 27/02/07

Primrose Court 08/12/05

Primrose Court 18/11/04

Primrose Court 21/07/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Primrose Court Orchard Way Guiseley West Yorkshire LS20 9EP Lead Inspector Valerie Francis Unannounced 17 May 2005 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 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 Court J52 S1492 Primrose court V226868 170505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Primrose Court Address Orchard Way Guiseley Leeds LS20 9EP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01943 875690 01943 871637 Anchor Trust Mrs C Drapier Care home 35 Category(ies) of Old age (35) Learning disability(35) registration, with number of places Primrose Court J52 S1492 Primrose court V226868 170505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17/11/04 Brief Description of the Service: Primrose Court is owned by Anchor Trust, a registered charity. Mrs Catherine Drapier manages it on their behalf. The care home provides accommodation and care services for up to thirty-five service users. However, at the present time the maximum number of service users is thirty-two. The numbers have been reduced, as the area, which was previously used by three service users, is now not being utilised. Primrose Court was built in 1986, it was the first care home of its kind, to be designed for the purpose. The home is on three floors. A passenger lift ensures all floors are accessible to service users. Primrose Court is situated alongside other housing, which provides sheltered accommodation for older people. These properties have no connection with the home. A warden is employed who oversees the sheltered housing. The care home is well served by public transport. There is a train station in close proximity.All rooms are allocated on a permanent basis. Unless there are vacancies, in which case the manager will consider offering short stays. All bedrooms offer single occupancy. There used to be one double bedroom, however this was decommissioned recently as the room did not meet current standards for two service users to share. Service users can eat their meals in their bedrooms should they wish. A communal dining area is available. Primrose Court J52 S1492 Primrose court V226868 170505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this inspection, which was unannounced over a day, which started at 9.40am and completed at 4 pm. The registered manager was on duty and facilitated in the inspection process. Comment cards were given to the manager for her feedback on the way in which the inspection was carried out. Comment cards for both residents and visitors and the new CSCI service users information leaflets were also given. The purpose of this inspection was to monitor the home’s progress since the last inspection and to assess whether the care given to residents meets minimum standards. During the inspection records were examined, some areas of the home were seen, such as bedrooms, lounges, bathrooms etc, observation was made of staff interaction, and discussions, both on an individual and joint basis, were held with the deputy, five members of staff, the administrator, four visitors, and twenty of the thirty five residents. During this time residents’ records and care plans were assessed, with residents and their relatives. What the service does well: What has improved since the last inspection? Primrose Court J52 S1492 Primrose court V226868 170505 Stage 4.doc Version 1.30 Page 6 The manager said plans are in place for the registered provider to issues the CSCI with copies of the monthly visit reports from June 2005. All residents have now been issued with contracts of residency. Work has been carried out to fire doors and they are now working correctly. New baths have been fitted in communal bathrooms, which have been retiled redecorated, and new floor covering laid. 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. Primrose Court J52 S1492 Primrose court V226868 170505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Primrose Court J52 S1492 Primrose court V226868 170505 Stage 4.doc Version 1.30 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 standard(s) 1,2,3,4 & 5 Prospective residents are able to access on their visit to the home, information about the facilities provided. The admissions process is effective, and residents receive relevant information and support. EVIDENCE: Since the last inspection a copy of the home’s statement of purpose has been sent to the CSCI area office, to ensure that it meet all the requirements, however, minor amendments are needed, i.e. Information on the age range of the residents to be cared for, and any specialist care offered. So that people wanting the service will have enough information when making a choice of a home. Residents living at the home have access to a service user guide, which provides them with information about the home. Each resident is given a terms and condition of residency. A member of the home’s management team carry out pre assessments, using the assessment document, which has recently been updated so that it meets with standard 2 of the National Minimum Standards, assesses prospective residents, carries out assessments. The new document offers the staff carrying out the assessment an aide memoir, to help them obtain enough information Primrose Court J52 S1492 Primrose court V226868 170505 Stage 4.doc Version 1.30 Page 9 so that a comprehensive care plan can be put in place covering all the assessed needs. Prospective residents and their carers have the opportunity to visit the home and to read the Statement of Purpose, which provides them with information to assure them the home can meet their individual needs. Primrose Court J52 S1492 Primrose court V226868 170505 Stage 4.doc Version 1.30 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 standard(s) 7,8 &10. It was acknowledged that although there was a good system for care needs assessment, no written plans of care for residents were in place. The home provides good healthcare and works effectively with healthcare services. EVIDENCE: Four residents care file were assessed. It was evident that staff had collected good information regarding each resident personal care, however, there were no plans of action how these needs would be met. In most cases there was evidence that an assessment of care needs had been carried out, life style agreement also outlined some of the care needs identified at the assessment document. The inspector discussed with the manager that all identified needs must have a plan of action detailing how these needs would be managed. Care plans must also include the social aspect of individual care, so that where possible the social activities of the individual are on going despite them living in a care home. Separate files are kept for contact with General Practitioners and other health care professionals. Primrose Court J52 S1492 Primrose court V226868 170505 Stage 4.doc Version 1.30 Page 11 Risk assessments are carried out for moving and handling, the manager said the District Nurses would assess anyone at risk of developing pressure sores. Residents, who the inspector spoke with, spoke highly of staff and the way in which they support them in a caring and respectful way always courteous. The inspector observed staff interaction with residents, whilst attending to them, they were friendly and supportive with out being overly friendly. Primrose Court J52 S1492 Primrose court V226868 170505 Stage 4.doc Version 1.30 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 standard(s) 12 and 14 Encouragement and support is given to residents to take part in activities in house and in the community and to make decisions about their life. EVIDENCE: Although there were no social care plans in place for staff to follow to meet the needs of residents, it was evident from discussion with residents that there was a range of social activities that they could take part in, if they so wished. The inspector observed the coming and going of residents to their activities outside the home. The home has good links with the nearby church; residents are invited to activities held at the church. From discussion with residents and their visitors it was evident that good support and encouragement is given for people to keep in contact. Transport can be arranged to take residents shopping with staff at nearby shopping centres. The home’s service user guide provides residents with information regarding social activities, contact with relatives and visiting arrangements at the home. Primrose Court J52 S1492 Primrose court V226868 170505 Stage 4.doc Version 1.30 Page 13 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 standard(s) 17 and 18. The home has a system in place so that residents and their visitors’ views are heard. There are good systems in place to protect residents from abuse. EVIDENCE: Residents and their visitors have access to a comprehensive complaints procedure, which can be found displayed in the home and in the statement of purpose and service user guide. The information provides names and address of all personnel that can be involved in dealing with complaint. From discussion with residents and their visitors they were confident that their complaint would be dealt with in a timely manner. Staff have access to policies and procedures, including a whistle blowing policy, which gives staff the opportunity with protection to report any incident of concern to management without feeling they would be victimised. The organisation document Rights and Responsibility give staff clear information’s on the protection of service users. Staff also have access to the Adult Protection policy procedure and the Department of Health No Secrets guideline and the local authority multidisciplinary adult protection procedure, which gives staff clear guideline what to do when an alleged abuse had occurred. Primrose Court J52 S1492 Primrose court V226868 170505 Stage 4.doc Version 1.30 Page 14 The manager said all staff are given a copy of the home’s adult protection procedure. Staff are made aware of adult protection issues at their induction and receive follow up training on adult protection. Primrose Court J52 S1492 Primrose court V226868 170505 Stage 4.doc Version 1.30 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 standard(s) 19 and 25. All effort is made to ensure that residents live in an environment that is safe and well maintained. EVIDENCE: Although in the main the building is well maintained, there were plans in place for extensive refurbishment and redecoration of the main sitting area. It was obvious that staff and resident have worked hard together to keep the building clean and well maintained. The inspector was also told that there were plans in place for major refurbishment of the flat on the top floor by creating four single bedrooms with ensuite facilities this also would increase the number of residents living at the home to thirty –six, the manager said she was aware that she had to notify the CSCI of any changes, she was reminded that application for the variation of numbers must be made and copies of the plans submitted. At the time of the inspection some of the communal bathroom were being retiled and redecorated with new baths fitted. Primrose Court J52 S1492 Primrose court V226868 170505 Stage 4.doc Version 1.30 Page 16 The inspector found that one of the bathrooms was subjectively dark, which some resident who have poor eyesight may find too dark and not able to see. The manager said she was aware of this and has made plans to increase the wattage of lighting in these rooms. When a bedroom becomes vacant the ensuite facilities are refurbished with new toilets sinks, floor covering and redecorated and showers removed. There are records in place of all safety checks carried out of the building, appliances and fire safety equipment. The West Yorkshire Fire Service recently inspected the home, which the manager said no recommendation was made. There is a contract for the garden maintenance in place, the garden was seen to be well maintained. Risk assessments are carried out of the building to ensure that all hazards are identified and action plans in place to manage the risks to residents and others in the home. Primrose Court J52 S1492 Primrose court V226868 170505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 30. Residents are supported and cared for by staff that have had training to meet their needs. EVIDENCE: All new staff have induction training in accordance with TOPSS, which providesthem with the basic knowledge and skill to care for residents and within six months of their employment staff receive foundation training which covers aspects of residents care. Training is provided for specialist care i.e. Dementia to ensure that staff have the knowledge to care for residents experiencing a dementia, also and safe handling of medication. There is a plan in place for training on Infection Control. There is on going National Vocational Qualification training (NVQ level 2), at the time of the inspection there were eight care staff with an NVQ level 2 qualification and the deputy manager is undertaking the registered managers award. During discussion with staff they spoke with pride of their ability to care for residents in a home that offers them support and provides them with training that would support them in their service delivery to residents and for their personal development. Primrose Court J52 S1492 Primrose court V226868 170505 Stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,34,37 and 38. The day to day management style of the home provides residents and staff with an environment that is open and supportive. The health and safety of residents are protected by all the regular checks carried out. EVIDENCE: The registered manager holds the registered manager’s award and HNC qualifications. There is on going training for the management team such as staff supervision, which would enable them to carry out one to one supervision with staff effectively. The manager and the deputy work closely together thus ensuring that ethos of the home is one that is open thus allowing residents, staff and their visitors the opportunity to speak to the management team when they wish. Primrose Court J52 S1492 Primrose court V226868 170505 Stage 4.doc Version 1.30 Page 19 The manager is involved in the budget planning which is discussed with the organisations’ Business Manager. There was no financial irregularity on the day of the inspection that gave the inspector reason for concern. The inspector spoke to four sets of relatives and it was obvious that they were aware of the records kept on behalf of their relatives and their involvement in the life style agreements. Resident’s records are kept in a locked filing cabinet, which is in a locked area. Generally all health and safety checks for the home are carried out, however, it was noted that the electricity check was due in January 2005; the manager said she this had been alerted and plans are in place for this to be done. Staff have access to the home’s Health and Safety policy procedures. All accidents and incidents are recorded; the CSCI is notified about accidents and incidents that have taking the person to the hospital and has affected the health and well being of residents. Primrose Court J52 S1492 Primrose court V226868 170505 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 3 15 x COMPLAINTS AND PROTECTION 3 x x x x x 3 x STAFFING Standard No Score 27 x 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x 3 x x 3 3 Primrose Court J52 S1492 Primrose court V226868 170505 Stage 4.doc Version 1.30 Page 21 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 1 Regulation 4 Requirement The home needs to improve the written information that should be given to people thinking about coming into the home. Each resident must have a plan of care for staff to follow, and staff must refer to this document rather than rely on verbal information. Without following a plan, important care needs may be missed. the home must make application for an incease of their number. Timescale for action 3rd August 2005 2. 7 15 3rd August 2005 3. 19 39 (h) 29th July 2005 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 Good Practice Recommendations Primrose Court J52 S1492 Primrose court V226868 170505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley LS13 1HP 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 Primrose Court J52 S1492 Primrose court V226868 170505 Stage 4.doc Version 1.30 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!