Inspection on 27/02/07 for Primrose Court

This inspection was carried out on 27th February 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Primrose Court 08/12/05

Primrose Court 17/05/05

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, Off Oxford Road Guiseley Leeds West Yorkshire LS20 9EP Lead Inspector Hebrew Rawlins Unannounced Inspection 27th February 2007 08:45 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 Court DS0000001492.V322010.R03.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. Primrose Court DS0000001492.V322010.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Primrose Court Address Orchard Way, Off Oxford Road Guiseley Leeds West Yorkshire LS20 9EP 01943 875690 01943 871 637 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) sharon.blackwell@anchor.org Anchor Trust Mrs Catherine Patricia Drapier Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Primrose Court DS0000001492.V322010.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2005 Brief Description of the Service: Anchor Trust, a registered charity, owns Primrose Court. 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 is a large sitting area on the ground floor, half of which is screened off and used as residents dining area. Service users can eat their meals in their bedrooms should they wish. The other half of the area is furnished with easy chairs and is used by residents as a communal sitting area. The current fees range single room with en-suite facilities £470.00 to £512.00 per week with additional charges for hairdressing, chiropodist, newspapers, toiletries and special trips out. This information was provided by the manager as part of the pre-inspection questionnaire completed before this inspection. Primrose Court DS0000001492.V322010.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk This unannounced key inspection took place at 8.45am on the 27th February 2007. The purpose of the visit was to monitor standards of care in the home and to look at progress in meeting the requirements and recommendations made at the last visit. The manager completed a pre-inspection questionnaire. The information provided has been used in the preparation of this report. The people who live in the home prefer the term ‘resident’ and this will be used throughout this report. Completed survey cards were received from relatives, health care professionals and residents. Comments from the survey cards can be found throughout this report. During the inspection I spoke to residents, staff on duty and relatives. I looked at records and made a tour of the building. Feedback at the end of this inspection was given to the deputy manager. I would like to extend my thanks to everyone who contributed to the inspection and for the hospitality during the visit. What the service does well: What has improved since the last inspection? Primrose Court DS0000001492.V322010.R03.S.doc Version 5.2 Page 6 Most of the requirements from the last inspection have been dealt with. Staff have had training in safe handling of medicine. Nutritional risk assessment is now carried out for each resident. The odour problem in a bedroom has been resolved. 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. Primrose Court DS0000001492.V322010.R03.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 Primrose Court DS0000001492.V322010.R03.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, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the opportunity to visit the home, stay for a meal and speak to other residents before making any decisions about admission. Effective systems are in place to assess service user needs before admission. All residents are issued with contacts that are reviewed on an annual basis. EVIDENCE: There is plenty of written information about the home for people to read. Copies of the statement of purpose and service user guide were and copies of previous inspection reports are made available to all. Four pre admission assessments were looked at. They were comprehensive and provided information to ensure staff could meet the needs of the resident. Primrose Court DS0000001492.V322010.R03.S.doc Version 5.2 Page 9 It was clear from discussion with residents that prospective residents are given the opportunity to visit the home as many times as they like. Four contracts issued to residents following their admission to the home were seen. The deputy manager stated that residents are informed, in writing, of the annual increase in fees. Primrose Court DS0000001492.V322010.R03.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service Residents’ health care needs are met, and the new paper work for care planning has the potential to provide a better care records if used properly. Medication practices are good and the home always follows safe guidelines and return unused medication to the pharmacy. EVIDENCE: In all of the care records sampled there was evidence of health needs being met, by dental appointments, chiropody visits, optical prescriptions and visits from GPs and district nurses. The home has a comprehensive medication policy that covers all aspects of recording and administering medication. Medication is stored in a safe environment. The storage and recording of controlled drugs was satisfactory. Four residents was case tracked using their individual care records. Primrose Court DS0000001492.V322010.R03.S.doc Version 5.2 Page 11 There was no indication in files those residents or their relatives being involved in the care planning process. There was evidence of the resident’s social activities and a pen picture informing staff about their life before moving to the home. Detailed and effective risk assessments are in place and provide staff with instruction on how to manage an identified risk. Observation and discussion with residents showed that staff respect their privacy and dignity. Patient and caring interaction was seen between residents and the staff. Input from other healthcare professionals is clearly documented within the records. Primrose Court DS0000001492.V322010.R03.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to make choices in their daily lives and to maintain contact with their friends and families. Visitors are made very welcome at the home. Residents are provided with a varied and nutritious diet. EVIDENCE: Visitors are made very welcome and offered refreshments and privacy for their visit. Visitors spoken with on the day of the visit said that they were always made welcome and the staff looked after their relative very well. The cook has been at the home for number of years and understands the needs of the residents very well. Residents eat their meals in the dining room or in their room. The furnishings were comfortable and domestic in type. Residents were very complementary about the standards of food. Primrose Court DS0000001492.V322010.R03.S.doc Version 5.2 Page 13 Residents said they were happy living at Primrose Court. They choose how and where they spend their day. One resident said, “ the food is very good and the staff cannot do enough to help me.” One resident prefers to spend time in her room listening to the radio, music and staff go in to chat when they can. Others come down to lounge at various times through the morning. A list of daily activities was seen in the entrance hall. This informed residents about what was happening in the home during the week. Primrose Court DS0000001492.V322010.R03.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The level of staff understanding gives assurance that any complaints would be taken seriously. Residents feel safe and staff are aware of adult protection. EVIDENCE: There is a complaints procedure in place that is made available to residents and their families. Residents and their families are clear about whom to talk to if they have an issue of concern. Staff are vigilant and intervene if they think residents have any concerns. Residents said they feel safe and well cared for. There have not been any recent complaints since the last inspection. Adult protection procedures are in place as well as whistle blowing procedures for staff. Primrose Court DS0000001492.V322010.R03.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, 25 and 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 clean and free of unpleasant odours. There is a rolling program of maintenances. EVIDENCE: The home was clean and there were no unpleasant odours. There are appropriate systems in place to reduce the risk of cross infection. Waste is disposed of properly. Residents’ rooms are welcoming and they are able to bring small personal items to help personalise their rooms. All the rooms have en suite facilities and several have been re-tiled with a program to do the rest shortly. However one resident said she is one of the first resident to live in the home and she has not had her en suite decorated whilst others who have come after her has. The deputy manager said her room and en suite is on the list to be done. The resident was also concern that she would have to pay extra once Primrose Court DS0000001492.V322010.R03.S.doc Version 5.2 Page 16 the work has been done. The deputy manager said as far as she is aware this would not be the case. The home has recently had two new baths fitted, decorated and carpeted rooms as new residents move in. A full redecoration of the corridors and staircases has been done and an ex-shared flat is now used as a training room. Several resident draws the inspector attention to the fact that windows in the home are not double-glazed and the home can be very cold at times. The home has appropriate systems in place to reduce the risk of cross infection. Waste is disposed of properly. Primrose Court DS0000001492.V322010.R03.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing arrangements appeared sufficient to meet the needs of the residents. Staff are well trained and competent to carry out their duties. EVIDENCE: Duty rotas indicated that there are sufficient care staff on duty to meet the needs of the residents. The cooks and cleaners support care staff in their role. The home has 50 of the care staff team qualified to NVQ (National Vocational Qualification) level 2 or above. All new staff receives induction training that meets national guidelines. The home has a good training programme and there are records of all training done by staff. Training needs are identified through supervision and appraisal. All the staff said the working environment and teamwork was very good. They gave examples for how they work together; covering each others work load and shifts when necessary. The recruitment files looked at on the day of the visit for recently employed staff were up to date. However the deputy manager was asked to make sure Primrose Court DS0000001492.V322010.R03.S.doc Version 5.2 Page 18 all documents are dated and signed. All the necessary checks are carried out before staff start work at the home. Primrose Court DS0000001492.V322010.R03.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 35, 36, 37 and 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 well managed. The manager provides good leadership to the staff and ensures the residents are protected and cared for in a correct manner. EVIDENCE: Residents said they would not hesitate to talk to the manager if they had any concerns and staff said they felt supported by the manager. The home administrator demonstrated a robust procedure for managing resident’s personal allowance monies held at the home. These are secure, but accessible when needed. Primrose Court DS0000001492.V322010.R03.S.doc Version 5.2 Page 20 All the required records were available and were in good order. No concerns with health and safety were identified during the inspection. Primrose Court DS0000001492.V322010.R03.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 3 3 3 3 3 n/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 X X 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 X X 3 3 3 3 Primrose Court DS0000001492.V322010.R03.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15 Requirement Care plans must have all care needs and how they would be met. (More work is still required from last inspection). Windows throughout the home should be double-glazed which will maintain the warmth throughout the winter. (Response by) Timescale for action 01/05/07 2. OP19 23 01/05/07 3. OP27 18 4 OP29 15 The registered provider must 01/05/07 make sure that staff have training in death and dying. (Raised at last inspection). The manager must make sure all 01/05/07 documents are dated and signed. Primrose Court DS0000001492.V322010.R03.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Primrose Court DS0000001492.V322010.R03.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Primrose Court DS0000001492.V322010.R03.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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