Inspection on 11/06/07 for Primrose Court Residential Home

This inspection was carried out on 11th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Primrose Court Residential Home 12/08/09

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Primrose Court Residential Home 241 Normanby Road South Bank Middlesbrough Cleveland TS6 6SX Lead Inspector Brenda Grant Key Unannounced Inspection 11th June 2007 10:10 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 Residential Home DS0000069082.V342420.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Primrose Court Residential Home DS0000069082.V342420.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Primrose Court Residential Home Address 241 Normanby Road South Bank Middlesbrough Cleveland TS6 6SX 01733 576451 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) Jay Mal Sangan Odedra Mrs Penny Hill Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Primrose Court Residential Home DS0000069082.V342420.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places: 24 2. The maximum number of service users who can be accommodated is: 24 Date of last inspection: This is not applicable. Brief Description of the Service: Primrose Court is a care home providing personal care for older people. It is a two-storey building providing single and shared accommodation for up to 24 residents. There are 18 single bedrooms and 3 double bedrooms; 17 bedrooms have an en-suit facility, with a wash-basin and toilet. There are stairs as well as a passenger lift, giving residents access to the first floor. Communal rooms are: a large lounge, conservatory and a dining room that has a seating area. Primrose Court has a small car part at the front of the building and the home is close to local shops and amenities. The fee, for residents at Primrose Court, is £445 weekly. Primrose Court Residential Home DS0000069082.V342420.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection. We assessed the information from: the Pre-Inspection Questionnaire and we carried out a visit to the home. The visit took place over one day, six hours fifteen minutes in total. Discussion took place with residents and a relative, care staff, the cook and the manager. We looked around the home and examined a number of records that included; residents and staff files, health and safety and maintenance checks and complaints, accident and kitchen records. The findings from the inspection were of the home providing a good care service with nearly all of the National Minimum Standards being met. What the service does well: What has improved since the last inspection? This is classed as a new service because the home has a new provider. Last inspection information is not applicable. Primrose Court Residential Home DS0000069082.V342420.R01.S.doc Version 5.2 Page 6 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 Residential Home DS0000069082.V342420.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Primrose Court Residential Home DS0000069082.V342420.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 3 & 6 Resident’s needs are assessed before moving to the home and they are assured those needs will be met. EVIDENCE: Residents who are funded by the local authority have assessments, carried out by a care manager, which are shared with the home. For those all residents, the manager carries out an assessment, so that Primrose Court can determine whether the needs of the person could be met at the home. The assessment includes details of: health, social and personal needs as well as social interests, Primrose Court Residential Home DS0000069082.V342420.R01.S.doc Version 5.2 Page 9 hobbies and religion. Two residents and a relative said, they were involved with the assessment process and they had the opportunity to look around the home and meet residents and staff before the resident was admitted. The home does not offer intermediate care therefore standard six does not apply. Primrose Court Residential Home DS0000069082.V342420.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 7, 8, 9 & 10 Resident’s health, personal and social care needs are fully met and this information is recorded in Care Plans. Residents are protected by the home’s policies and procedures for dealing with medicines. Residents are treated with respect and their right to privacy is upheld. EVIDENCE: The home develops Care Plans for each resident. There is information about the person’s health, social and personal care needs and the plans are regularly reviewed. A relative said, “We are kept informed about anything that happens in the home and we are involved when there are reviews of Care Plans”. Care Plans provided information about how each resident’s care was delivered. Residents and or relatives signed the Care Plans, confirming they agreed with them. Primrose Court Residential Home DS0000069082.V342420.R01.S.doc Version 5.2 Page 11 Care Plans included a Risk Assessment that informed how those risks were to be managed; to reduce those risks to an acceptable level. Resident’s files included healthcare visits and appointments; the details were recorded in the general information. Residents healthcare needs were being met but the reader, of the record, could not readily see the regularity of visits for treatment from: GPs and District Nurses, opticians, chiropodists, dentists and other healthcare specialists. The home’s takes appropriate action for managing resident’s medicines. The storage and recording was found to be satisfactory. Resident’s files included assessment details for whether it was suitable for a resident to look after their own medicines. At the time of the inspection ‘site’ visit the home did not have any residents who were in control of their medication. Staff files confirmed staff has completed medication awareness training. Staff were observed being respectful to residents and knocking on bedroom doors before entering the room. The relationship between staff and residents was very relaxed and residents spoken with confirmed they were treated with respect. One resident said, “The staff are very caring”. All comments, from residents and a relative, were very complimentary about how staff looked after residents. One resident said, “They (the care staff) are great” and a relative said, “Everything here is satisfactory and residents are very content”. Primrose Court Residential Home DS0000069082.V342420.R01.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards: 12, 13, 14 & 15 Residents live their lives as they wish and residents maintain contacts with families and friends. Residents have choice and control over what they do. The home provides a varied and balanced diet but kitchen records are not always completed. EVIDENCE: Staff said the home tries make sure residents social, cultural and recreational interests are catered for. The manager informed there were future plans to have a programme of recreational activities offered at the home. One resident said, “We like the entertainment and games the organised for us”. The home provides for resident’s religious needs; by arranging regular visits, at the home, from three different religious sects. The manager said, “If it was not already provided for, the home would always make suitable arrangements to meet resident’s religious and cultural needs”. On the day of the inspection ‘site’ visit there were some residents who wanted to sit outside in the sunshine. After lunch, staff made arrangements for those residents to sit outside at the front of the home. Residents enjoyed having a chat with each other and all of Primrose Court Residential Home DS0000069082.V342420.R01.S.doc Version 5.2 Page 13 the home’s residents were offered a ‘choc-ice’. Staff said they sometimes accompany residents to the local shops, the library or just to go out for a walk. Residents and staff said, relatives and friends were always made to feel welcome when they visited the home. Staff said the home has regular contact with resident’s families. One relative said, “The manager and staff are always friendly, they regularly contact me and I am always kept informed about what is happening at the home”. Residents said, they felt they were in control of their lives and they lived their lives as they wish. One resident said, “Staff are always considerate and we make our own decisions” and another resident said, “I can please myself with what I want to do”. Residents said, they were able to bring their personal possessions and have their bedrooms arranged as they wish. The home accommodated for residents who wanted to: get up early or late, stay in their bedrooms or go to communal rooms. The home’s menus were examined; they did not give full information about the food offered to residents. On the day of the inspection ‘site’ visit the manager altered the menus so that they gave more detailed information. The manager said she would make arrangements for the menus to be in larger print so they would be easier for residents to read. All residents spoken with said the food was very good. The food stored at the home was of there being fresh fruit and vegetables and a good variety other foods. The cook kept a record of the food that had been served to residents but kitchen records had not been fully completed for: the cleaning rota, fridge, freezer and food temperatures. We noticed the kitchen ceiling, above the cooker, to have peeling paint and we informed the manager food could be contaminated if any peeling paint fell into the food. The day following the inspection ‘site’ visit, the manager told us that area of the kitchen ceiling had been redecorated. Primrose Court Residential Home DS0000069082.V342420.R01.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 16 & 18 Residents are confident their complaints will be listened to, taken seriously and acted upon. Residents are protected from abuse by the home’s policies and procedures. EVIDENCE: The home has a satisfactory complaints procedure. Residents and a relative spoken with informed, they did not have anything to complain about but they were confident any complaints would be appropriately dealt with. Since the last inspection the home had not received any complaints. The manager had a ‘thank you’ card that complimented the manager and staff for the care they had given to a resident. The home has procedures for protecting residents from abuse. Staff records confirmed staff had completed training for safeguarding vulnerable adults but some training had been completed a few years ago. The manager said she will make arrangements for staff to receive an update with their training, to raise staff’s awareness for safeguarding adults. Staff said, they knew of the procedures to follow if there was an allegation of abuse on a resident and staff said they were aware of the Whistle Blowing Policy. Primrose Court Residential Home DS0000069082.V342420.R01.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards: 19 & 26 In the main, residents live in a safe and well-maintained environment. The home is clean, pleasant and hygienic and free from offensive odours. EVIDENCE: Primrose Court provides a homely and comfortable environment for residents. The manager informed, there are plans to redecorated some areas of the home and replace some carpets and furniture. Presently some areas around the home need to be redecorated and there are places where there is worn carpeting. One resident said, “The cushions of some of the chairs are a bit flat and not very comfortable”. Residents said they were pleased with a new television and residents said they were going to help choose the colour scheme for when the lounge is redecorated. The manager said, “Decorators have been introduced to the residents and there are plans for the decorating to be carried Primrose Court Residential Home DS0000069082.V342420.R01.S.doc Version 5.2 Page 16 out after residents have retired for the evening. This is so there is little or no disruption for the residents”. The bathroom, used by most residents, had scuff marks on the bath surface and the panelling around the bath was badly scraped. The home’s maintenance records were examined and found to be satisfactory. The requirements of the Environmental Health Department had been met and all fire safety measures were in place. The fire alarm weekly checks were recorded and gave details the different fire points that had been tested. The home was clean, pleasant, hygienic and free from offensive odours. A relative commented, “The rooms are always kept clean and tidy”. Laundry facilities were on the upper floor and there was regular maintenance of the washing and drying machines. Primrose Court Residential Home DS0000069082.V342420.R01.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 27, 28, 29 & 30 Resident’s needs are met by the numbers and skill mix of staff who are trained and competent to care for the residents at the home. Residents are protected by the home’s recruitment procedures. EVIDENCE: On the day of the inspection ‘site’ visit there was sufficient staff on duty to meet the needs of the residents who presently live at the home. That day the house-keeper was unavailable for work but all staff managed very well, to make sure residents needs were met. One staff said, “We always work as a team and we make sure all staff know what there is to do”. It is commendable that all of the care staff, with the exception of a newly employed care assistant, has successfully completed the National Vocational Qualification at Level 2. The new employee said s/he is going to register for the training course. Additionally, there were nine staff who are undergoing Level 3 of the qualification. Staff, spoken with, and staff files confirmed the home follows the recruitment procedures. The new member of staff informed that those procedures had been followed. Primrose Court Residential Home DS0000069082.V342420.R01.S.doc Version 5.2 Page 18 Staff’s training files confirmed staff had completed basic and further training and senior care staff had completed training for safe handling of medicines. Additionally, some staff had completed training for care of the dying. The training records did not wholly make it clear when training needed to be updated. Primrose Court Residential Home DS0000069082.V342420.R01.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 31, 33, 35 & 38 The home is well managed and run in the best interests of the residents. Residents are included with any developments and improvements that take place. Resident’s personal monies are safeguarded by the home’s procedures. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The manager has recently successfully completed an appropriate management qualification. She already has a National Vocational Qualification Level 3 and this year is to register for Level 4 training of the qualification. The manager has many years of experience running a care home for older people. Staff said, Primrose Court Residential Home DS0000069082.V342420.R01.S.doc Version 5.2 Page 20 the manager gives support when it is needed and residents said they thought the home was ‘well run’. The home carries out quality assurance monitoring by residents and/or their relatives completing a survey questionnaire. The home has devised a report to compile the results of the survey. Staff, residents and a relative confirmed there is regular consultation about the running of the home, so they are included with any improvements and developments that take place. The manager said she was considering putting a ‘suggestion box’ in a communal area so that people can give their views any time they are at the home. The manager carries out regular audits of the service, records of the audits were available at the home. The manager informed the new provider is making arrangements to carry out monthly monitoring visits. The manager said, residents were encouraged to look after their own money and residents are provided with a lockable drawer, for safe keeping of valuables. The home was not involved in financial transactions on behalf of residents. The health and safety records were examined and found to be in order. The manager keeps an up to date record of all maintenance and checks that are required throughout the year. Staff had completed health and safety training and the home provides protective clothing for staff’s use. Electrical equipment checks were up to date and there is documentation for the Control Of Substances Hazardous to Health. It was confirmed that the home meets the requirements of the Environmental Health Department. Records are generally up to date. The home keeps records of all accidents and an accidents analysis is carried out. The accident records were not kept as directed in the accident record booklet. The home regularly checks the hot water outlet temperatures, in resident’s accommodation, which is controlled by thermostatic valves. The manager also makes sure measures are taken to treat stored hot water, to reduce the risk of Legionella. Primrose Court Residential Home DS0000069082.V342420.R01.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 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 2 X 3 X 3 X X 2 Primrose Court Residential Home DS0000069082.V342420.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? N/a 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 OP15 Regulation 13 Requirement Kitchen records for: cleaning rota, freezer/fridge/food temperatures must always be completed, for the safety of residents. Some areas where there are grubby walls must be redecorated. Worn carpeting and furniture, that has flattened cushioning, must be replaced, for the comfort of residents. The scuffed bath surface and panelling around the bath must be made good. Timescale for action 31/07/07 2. OP19 23 31/10/07 3. OP38 17 Accident records must be kept as 31/07/07 directed in the accident record booklet, for the protection of information relating to residents and staff. Primrose Court Residential Home DS0000069082.V342420.R01.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. 1. 2. Refer to Standard OP18 OP31 Good Practice Recommendations All staff should complete up to date training, for safeguarding vulnerable adults. The manager should have a qualification at National Vocational Qualification Level 4 in care or equivalent. Primrose Court Residential Home DS0000069082.V342420.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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. 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