Inspection on 08/12/05 for Primrose Court

This inspection was carried out on 8th December 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 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 27/02/07

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 Valerie Francis Unannounced Inspection 8th December 2005 2:30 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 Court DS0000001492.V262587.R01.S.doc Version 5.0 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.V262587.R01.S.doc Version 5.0 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) Anchor Trust Mrs Catherine Patricia Drapier Care Home 35 Category(ies) of Learning disability (35), Old age, not falling registration, with number within any other category (35) of places Primrose Court DS0000001492.V262587.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th May 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. Primrose Court DS0000001492.V262587.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced. It started at 2.30pm finishing at 8pm The manager was working on this day. The time was spent looking at some documents, which included, care plans, staff recruitment files, medication records, minutes of meetings with residents and staff and maintenance records. 14 residents and 4 staff were spoken to about living and working at Primrose Court. The views of visitors are included in the report. The inspector looked around part of the building. The atmosphere within the home was open, friendly and welcoming. There was a sense of homely environment where residents felt and looked relaxed going about their business, residents went to bed when they wanted, many had chosen to have their baths in the evening before going to bed. The manager was given feedback about the inspection findings at the end of the inspection. What the service does well: What has improved since the last inspection? There has been some improvement in the quality of recording relevant information in residents care plans by staff. Primrose Court DS0000001492.V262587.R01.S.doc Version 5.0 Page 6 The home needs to improve the written information that should be given to people thinking about coming into the home. The home has made application to decrease the number of people accommodated in the home. Thus losing the upstairs flat that once accommodated three people. 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 DS0000001492.V262587.R01.S.doc Version 5.0 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.V262587.R01.S.doc Version 5.0 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): 1 & 3. Prospective residents are able to have access to clear and accurate information about the home. Systems are in place to assess prospective resident’s needs before admission. EVIDENCE: The home’s statement of purpose has been reviewed so that it has information that is current and up to date, meets the requirement of the regulations, and will provide prospective residents their relatives and others with enough information about the services given at the home, to enable them to choose whether or not they wish to live in the home. Although it was apparent in care files that a copy multi disciplinary assessment is given to the home before admission, these are not always up to date, therefore a pre-assessment is carried out by the home to allow them to have up to date information that would enable them when meeting people’s care needs. Primrose Court DS0000001492.V262587.R01.S.doc Version 5.0 Page 9 Since the last inspection the format has been revised to allow the collection of good information. Thus allowing staff to have enough information to put together a comprehensive care plan. Primrose Court DS0000001492.V262587.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 & 11. A new format for care plans are now in place. Not all resident had a full care plan in place for all needs identified in the preassessment document. The medication policy procedure was not in line with the Royal Pharmaceutical Society (RPS) guidelines for residential homes. Training is being provided to put systems in place for the care of residents coming to the end of their life. EVIDENCE: Three residents care files were seen. Although a new style care plan has been put in place, the format is the same as the pre–assessment, and although there was good information on the pre-assessment not all the care needs identified had a plan in place. One resident was receiving care visits from the district nurse and although there were nursing notes there was no indication on the individual care file that there was an issue which was being dealt with by the district nurse. Primrose Court DS0000001492.V262587.R01.S.doc Version 5.0 Page 11 Although reviews take place there was no plan of care of any newly identified care needs. The manager said that residents and their relatives are involved in their care, however there was no signature on file to indicate this. The manager was reminded that the lack of information in care plans could cause residents care needs to be missed. Residents sign to indicate if they wished to self medicate or for staff to administer their medication. Medication is reviewed regularly with the individual GP. All staff administering medication have had a one day training on safe handling of medicine but not a certificated course, it is acknowledged that they have access to procedure in place for medication. Although staff follow the RPS guideline when ordering medication the procedure was not in line with the guideline which must sure that all repeat prescriptions are sent back to the home and be signed by staff before going to the pharmacy. There was no information for residents’ last wishes on their care files, or a plan of care how their wishes would be carried out. The manager told the inspector of a four days course “ End of Life”, that she was attending. The plan in place was for all senior management to attend and for staff to receive cascade training from the home manager. The manager said that the course would enable them to care for residents, covering areas of care needs for someone who is dying. Primrose Court DS0000001492.V262587.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 & 15. There are a variety of social activities on offer to residents. Staff give residents support to keep in contact with people outside of the home. The food provided is in accordance with the choice of residents. EVIDENCE: There is a designated member of staff who has been allocated 20hrs a week as activity co-ordinator, whose role is to speak to residents on a one to one basis and in a group, planning social activities. There are also individual social plans of care, which identifies the past and present hobbies, and social actives people wish to get involved in. The manager said that all care staff also take part in the planning and working with residents in activities thus using the skill within the staff team. There is a residents committee where relatives, residents and a member staff meet to discuss issues that concern home life and activities. As part of the home’s written information residents can see their visitors at any time in accordance to their wishes. Residents can see their visitors in the privacy of their room. Support is given to residents if they wish to visit families and friends by the use of private transport or the access bus. Primrose Court DS0000001492.V262587.R01.S.doc Version 5.0 Page 13 The home has good working relationship with local church for which residents have the opportunity to attend services and activities they might have. Residents with staff support use the local shopping area. The home main meal is served at lunchtime with a light meal in the evening, which in the main is individual choice. Nutritional risk assessments were not in place for all residents. Residents like and dislikes of food is recorded in their care file, the manager said the catering manager speaks to all new residents about their food preferences and after meals for feedback about the food served. The manager said a new questionnaire has given to residents for feedback about their food preferences. Primrose Court DS0000001492.V262587.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 There are systems in place for service users legal rights to be protected. EVIDENCE: The home works with Age Concern Advocacy, however, the home has joined an advocacy organisation that will provide advocates for residents who do not have any families or friends to advocate on their behalf. Residents have the opportunity to vote, which is either at polling stations in the community, or postal votes. Primrose Court DS0000001492.V262587.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20, 21,22,23,24 & 26. Residents have access to a well-maintained environment, which is safe and comfortable for the needs of the residents. The gardens and grounds are well kept. EVIDENCE: The communal areas in the home are well maintained offering residents facilities that would meet their needs. Residents can use sitting areas to meet with their visitors and sit and speak with other residents. The area is split into two areas, one use for dining which has the appropriate furniture, and the sitting area, which is furnished with comfortable chairs, set out to create a homely environment. The manager said specialist equipments are provided to make sure that the needs of residents are met. Primrose Court DS0000001492.V262587.R01.S.doc Version 5.0 Page 16 There are only single rooms. The people living at the home have taken the opportunity to furnish their rooms to their taste and comfort. All bedrooms have ensuite facilities. Some residents had a fridge and snack making facilities in their room. The home was seen to be cleaned to a high standard, however one bedroom had an odour, this was reported to the manager who was aware, this must be addressed with the replacement of the carpet with an alternative type of floor covering found that would meet the needs of the resident living in that room. Primrose Court DS0000001492.V262587.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30. Residents have access to staff that have training and experience to meet the their needs. Residents are protected by the home’s recruitment and selection policy and procedure. EVIDENCE: The staffing levels at the home appeared to be enough to meet the need of the present group and number of residents. At the time of the inspection there was one part time night care staff vacancy. There are nineteen care staff employed at the home, nine of which the manager said has an NVQ 2 qualification, giving the home 50 of the care staff with an NVQ. Some staff have gone on to undertake NVQ 3. Both the manager and the deputy have undertaken and completed the Registered Manager Award course. All new staff goes through the organisations recruitment and selection process and a CRB and POVA first check before they take up employment. All staff have received a copy of the General Social Care Council code of conduct information. Induction training is given to all new members of staff. Training needs are discussed during the one to one staff supervisions. Primrose Court DS0000001492.V262587.R01.S.doc Version 5.0 Page 18 The manager said ten members of staff was undertaking an Infection Control Training. However, no staff have had dementia awareness training, the manager said she was looking at a course for care staff. Primrose Court DS0000001492.V262587.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35,36 & 38. Residents and staff are consulted about the standards of service. The manager is experienced in managing services for older people. The home seeks the views of residents and their visitors to monitor quality of service provided at the home. The health and safety of residents and staff is promoted. Staff receive regular supervision, which gives them the opportunities to discuss their personal development. EVIDENCE: There are systems within the organisation to review the quality of service, which is through the Hospitality Award quality system, which seeks the views of residents and their relatives. There is a record of all financial transaction of residents personal monies made by staff on behalf of residents. The system within the company is that residents money is kept in “the residents bank account”, residents money is pooled together and kept in the home for which individual record are kept, the manager said residents have Primrose Court DS0000001492.V262587.R01.S.doc Version 5.0 Page 20 access to their money at any time. Some discussion was had with the manager regarding the system for pooling resident money the system in place is unacceptable. Resident’s monies must be kept individually. Resident must have individual bank account, which is interest bearing. Staff have one to one supervision six weekly, which is carried out by a member of the home’s management team of which there are three. Staff meetings are held six monthly or more that was said depended if there was any new development that needed to be discussed with the team. Records of these meetings are kept and are made available to any staff that did not attend the meeting. There is regular health and safety checks on the building and equipment used by staff for residents. Portable electrical appliances had evidence of testing. Primrose Court DS0000001492.V262587.R01.S.doc Version 5.0 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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X X 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 3 2 3 X 3 Primrose Court DS0000001492.V262587.R01.S.doc Version 5.0 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 2 3 4 5 6 Standard OP7 OP30OP9 OP27 OP8 OP26 OP35 Regulation 15 18 18 13 & 16 23 12.4 (a b) Requirement Care plans must have all care needs and how they would be met. Staff must have certificated training in safe handling of medicine. The registered provider must make sure that staff have training in death and dying. Nutritional risk assessment must be carried out for each resident. The odour problem in the bedroom identified to the manager must be resolved The home must find another system for storing resident’s monies rather than “pooling” system in place. Timescale for action 31/01/06 31/01/06 31/01/06 20/01/06 10/01/06 31/01/06 Primrose Court DS0000001492.V262587.R01.S.doc Version 5.0 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. 1 2 Refer to Standard OP7 OP9 Good Practice Recommendations There should be some indication in care files that service users or their relatives being involved in the care planning process. The organisation should make sure that the medicine policy procedure for handling medicine is in line with the RPS guidelines for residential homes. Primrose Court DS0000001492.V262587.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds 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 DS0000001492.V262587.R01.S.doc Version 5.0 Page 25 - 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!