Inspection on 11/10/05 for Primrose Croft

This inspection was carried out on 11th October 2005.

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 Croft 18/09/07

Primrose Croft 26/11/06

Primrose Croft 03/05/05

Primrose Croft 07/09/04

Primrose Croft 06/04/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Primrose Croft Victoria Road Cambridge CB4 3EH Lead Inspector Janie Buchanan Unannounced Inspection 11th October 2005 09:00 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 Croft DS0000015237.V253242.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 Croft DS0000015237.V253242.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Primrose Croft Address Victoria Road Cambridge CB4 3EH 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) 01223 354773 01223 566549 Excelcare Holdings Ruby Davis Care Home 38 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (38) of places Primrose Croft DS0000015237.V253242.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd May 2005 Brief Description of the Service: Primrose Croft is one of five residential homes in Cambridge owned by Excelcare. It offers accommodation and personal care to 38 older people, some of whom have dementia. It is situated in a residential area north of the river Cam. It is within walking distance of all local amenities round Mitcham’s Corner and is a short drive away from Cambridge town centre. The home has undergone a refurbishment programme that included internal reconstruction to create eight new bedrooms with en-suite facilities and the creation of a unit for older people with dementia occupying the whole of the first floor. The home offers thirty-eight single bedrooms and there are a variety of communal rooms for residents to use. Pleasant gardens surround the home. Primrose Croft DS0000015237.V253242.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s second inspection for the year 2005/6 and was unannounced. The inspector interviewed four residents, four members of staff and the manager. She also spoke briefly with a community health care assistant who was visiting one of the residents. A tour of the home was undertaken and a range of documents was viewed. What the service does well: What has improved since the last inspection? What they could do better: Staff’s knowledge about the different kinds and symptoms of dementia remains poor and more must be done to ensure that staff have the appropriate training, skills and expertise to look after this particular resident group. The dementia care unit should only be staffed by workers who can effectively communicate with these residents. All staff should receive formal supervision with their line manager so that there is opportunity to discuss their working practices and identify their training needs. Primrose Croft DS0000015237.V253242.R01.S.doc Version 5.0 Page 6 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 Croft DS0000015237.V253242.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 Croft DS0000015237.V253242.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 Information available about the home is good providing residents and prospective residents with details of the home’s services and enabling them to make an informed decision about where they live. Pre-admission assessments are completed for all residents so that they know the home can adequately meet their needs. EVIDENCE: The home has a statement of purpose and service user guide, both of which give good information about the services and facilities on offer. These are available in large print for visually impaired residents. The inspector viewed three residents’ files and each contained appropriate preadmission assessments completed by the home’s manager or a care manager. The manager stated that all prospective residents are invited to time at the home prior to their admission in order to sample daily life and ensure that the home meets their needs. Primrose Croft DS0000015237.V253242.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9,10 Residents’ needs are reviewed regularly and care staff maintain their privacy and dignity. EVIDENCE: Three care plans were viewed and the information they contained was generally satisfactory. Residents’ needs in relation to washing, dressing, continence management, mobility, medication and mental health were clearly recorded, and there was evidence that these needs were reviewed monthly. Some residents had signed their plans to indicate their agreement of its contents. On the day of inspection itself the manager was undertaking an audit of the plans to ensure their accuracy and detail. The home’s practices ensure that residents’ privacy and dignity are maintained. Some residents are able to have their own telephone in their bedroom and those that don’t have access to a mobile phone. All mail is delivered to residents unopened, or kept for their relatives to open on their behalf. Laundry systems are in place to ensure that residents wear their own clothes at all times and GP consultations take place in the privacy of residents’ bedrooms. Staff interviewed by the inspector gave many good practical Primrose Croft DS0000015237.V253242.R01.S.doc Version 5.0 Page 10 examples of how they maintain residents’ dignity whilst helping them and residents confirmed that they received personal care in a way that they liked. One resident commented ‘she [carer] gives a lovely bath, I always look forward to it’. Primrose Croft DS0000015237.V253242.R01.S.doc Version 5.0 Page 11 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): 12,13,14,15 Daily routines at the home are flexible and residents’ preferences are respected. EVIDENCE: The home continues to provide frequent and varied activities for residents, details of which are prominently advertised around the home. On the morning of the inspection staff were helping residents on the dementia care unit exercise with a ball, and in the afternoon the residents were painting mobiles with the activities co-ordinator. Residents are able to receive visitors in private and there are no visiting restrictions in place. Residents’ families and friends are encouraged to take part in the life of the home and are invited to coffee mornings and other special occasions. One resident’s wife runs a raffle for the home and a staff member commented ‘we always get the sherry out when [resident B’s] family come’. Routines of daily living at the home are flexible and residents are able to exercise choice in what they do. One resident commented: ‘ I go to bed when I feel like it, generally between 9 and 10 pm’ another: ‘I can please myself, they let me sleep in if I want’. One resident prefers not to eat with the other residents and staff bring her meal to her in her bedroom. There is always a choice of what to eat at mealtimes and on the day of inspection residents Primrose Croft DS0000015237.V253242.R01.S.doc Version 5.0 Page 12 were enjoying a lunch of chicken casserole and vegetables or Cornish pasty and vegetables. Primrose Croft DS0000015237.V253242.R01.S.doc Version 5.0 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 the following standard(s): 16 Complaints are taken seriously, and dealt with promptly and thoroughly. EVIDENCE: The complaints procedure is displayed in the main entrance of the home and a copy of the procedure is also included in the service user guide. A copy of each complaint is sent to Excelcare’s regional office for monitoring and there is a system in place for ensuring that all complaints are responded to within the given timescale. The inspector viewed the complaints file: recent complaints concerned residents’ clothing going astray, missed medication and staff’s ability to understand and speak English. These complaints had been thoroughly recorded and responded to. A laundry assistant has recently been employed by the home in response to complaints about clothing going missing. Primrose Croft DS0000015237.V253242.R01.S.doc Version 5.0 Page 14 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): 19,20,25,26 Residents live in a comfortable and safe environment where there are good infection control measures in place to protect them. EVIDENCE: There are a variety of communal spaces for residents to use within the home including three lounges, three dining areas, and a small area where residents can sit comfortably in the corridor overlooking the front of the home. A quiet room can also be made available for residents who want to entertain guests. There are pleasant gardens surrounding the home that are accessible to the residents. Residents’ bedrooms meet all the minimum size requirements and ten of the bedrooms have ensuite facilities. The home was seen to be well maintained, hygienic and clean on the day of inspection and staff showed good awareness of how to prevent cross infection. Two residents currently have MRSA and additional infection control measures had been put in place for them. Liquid soap and paper towels are available in toilets and bathrooms, as well as posters reminding staff to wash their hands. Primrose Croft DS0000015237.V253242.R01.S.doc Version 5.0 Page 15 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 Staffing numbers are sufficient to meet residents’ needs, however not all staff have sufficient knowledge to look after those residents with dementia. EVIDENCE: Staffing levels are satisfactory. There are six members of staff and one team leader on between 8am and 2pm, and five members of staff and a team leader on between 2pm and 8pm to support 33 residents (currently). There are three waking night staff. The home was fully staffed on the day of inspection and scrutiny of the duty rota showed these staffing levels to be maintained. Both residents and staff interviewed felt these levels were adequate. The home employs a number of overseas staff: 4 from India, 2 from Poland, 1 from the Ukraine and 1 from Romania. The inspector spoke with some of these staff who had varying levels of spoken English. Although overseas staff have English language tuition as part of their induction, their ability to communicate with residents has been the subject of a recent formal complaint made by a resident. The inspector interviewed a visiting health care professional who also stated ‘ I’m not always convinced the foreign staff really understand what I say sometimes’. On the day of inspection itself three overseas staff were working in the dementia care unit. Although their care practices were excellent, it was of concern that these staff may not be in the best position to communicate effectively with residents and lack a shared cultural experience and history that is vital when engaging with people with dementia. It was also of concern that two staff on this unit had not undergone any training in dementia care and Primrose Croft DS0000015237.V253242.R01.S.doc Version 5.0 Page 16 were uncertain of the different types of dementia and common symptoms of the disease. The manager assured the inspector that training in this matter is planned soon at Cambridge Regional College. Primrose Croft DS0000015237.V253242.R01.S.doc Version 5.0 Page 17 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): 31,36,37,38 Residents’ are protected by the home’s policies and procedures, as well as its health and safety practices. EVIDENCE: There are regular staff and residents’ meetings at the home and staff stated that they felt well supported by the management team. One commented: ‘there is good teamwork here, despite the varying nationalities of staff’. Care staff do receive formal supervision, although it was of concern to note that one member of staff had received only one supervision in the last year. Another member of staff had not received any supervision since returning form maternity leave. The home has comprehensive written policies in place and the inspector viewed a sample of these policies including drug administration, whistle blowing, falls prevention and missing person’s procedure. Primrose Croft DS0000015237.V253242.R01.S.doc Version 5.0 Page 18 Health and safety is taken seriously by the home and files viewed by the inspector showed that staff had received up to date training in moving and handling, first aid, infection control, food hygiene and fire safety. Primrose Croft DS0000015237.V253242.R01.S.doc Version 5.0 Page 19 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 3 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 3 x x x x 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x x 2 3 3 Primrose Croft DS0000015237.V253242.R01.S.doc Version 5.0 Page 20 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 9 Regulation 13(2) Requirement The registered person shall ensure that persons employed at the home receive training appropriate to the work they are to perform. All staff who regularly work on the homes dementia care unit must receive training in the different types of dementia, the stages of the disease and person centred care. Previous timescale of 1 October not met. Timescale for action 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard 36 31 Good Practice Recommendations All care staff should receive supervision at least six times a year. The manager should complete the registered manager’s award. Primrose Croft DS0000015237.V253242.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 Croft DS0000015237.V253242.R01.S.doc Version 5.0 Page 22 - 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. 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