Inspection on 18/09/07 for Primrose Croft

This inspection was carried out on 18th September 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 Croft 26/11/06

Primrose Croft 11/10/05

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 18th September 2007 10:00 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.V351090.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 Croft DS0000015237.V351090.R01.S.doc Version 5.2 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 Primrose Healthcare Ltd 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.V351090.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th November 2006 Brief Description of the Service: Primrose Croft 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. Fees vary between £361 and £445. A copy of the most recent inspection report is available in the hallway of home for visitors and relatives to read. Primrose Croft DS0000015237.V351090.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the 18 September and was unannounced. The inspectors spent four and a half hours at the home and talked with six residents, three members of staff and the manager. 19 completed questionnaires from both residents and their relatives were also received. The overwhelming majority of respondents’ expressed a high degree of satisfaction with the quality of care, staffing and activities. However, two respondents had concerns about poor clothes laundering at the home, and two felt that staff were sometimes rushed. A tour of the home was undertaken and a number of documents, including residents’ medication records, were viewed. Three requirements have been made as a result of this inspection. What the service does well: What has improved since the last inspection? There have been many improvements in the home since the last inspection: • • • • A specific member of staff has been employed to ensure that residents receive a variety of activities and stimulation The purchase of new activities equipment, DVDs and TVs for each unit will ensure residents are better entertained There were no strong smells around the home Long corridor walls on the dementia unit have been decorated with paintings and stencils to provide a more stimulating and varied environment for residents who spend a lot of time wandering up and down them Staff have undertaken comprehensive training with the local community mental health team which will help them better understand the needs of those with dementia in their care. DS0000015237.V351090.R01.S.doc Version 5.2 Page 6 • Primrose Croft • A newsletter for residents and their relatives is now being produced regularly to keep them up to date with events around the home, and staffing news. 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 Croft DS0000015237.V351090.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 Croft DS0000015237.V351090.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): 1,2,3,5 Quality in this outcome area is good. Information available about the home is good providing prospective residents with details of the home’s services and enabling them to make an informed decision about where they live. Residents are thoroughly assessed before being admitted so their needs can be fully met at the home. This judgement has been made using available evidence including a visit to this service. 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. Prospective residents and their relatives are also encouraged to visit the home to assess its facilities. One relative stated ‘I chose this home rather than the others as staff seemed genuinely concerned about my feelings, and my mother’s, when we visited’. Every resident is issued with a contract that clearly states the terms and conditions of their stay at the home, and the fees payable by them. Primrose Croft DS0000015237.V351090.R01.S.doc Version 5.2 Page 9 The files for two recently admitted residents were viewed and each contained appropriate pre-admission assessments of their needs completed by a senior member of staff at the home. Primrose Croft DS0000015237.V351090.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): 7,8,9,10,11 Quality in this outcome area is good. Residents’ needs are clearly recorded in the care plans, and their health is monitored closely. However residents should be more actively involved in planning and reviewing their care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three residents’ care plans were viewed. The information they contained was generally detailed and residents’ needs in a number of areas including washing, dressing, continence, mobility and communication were clearly documented. Residents’ needs had been reviewed regularly. However, there was little evidence that residents actively participate in planning and reviewing their care. One very able resident told the inspector that she had never seen her care plan and a member of staff told the inspector residents only ever see their plans if they actually ask. The plans are not in a format that is easily accessible to residents. Residents’ weights, nutrition, falls risk and dependency levels are assessed regularly and those spoken to confirmed that they see a range of health care professionals. One visiting community psychiatric nurse who completed a questionnaire wrote: ‘communication is always good and staff respond well to Primrose Croft DS0000015237.V351090.R01.S.doc Version 5.2 Page 11 the changing needs of my patients’. One resident stated that a ‘very efficient and nice’ member of staff had accompanied her to the hospital the previous day and had stayed with her throughout, what she described, as a gruelling day. She also praised another member of staff for waiting to put her eye drops in even when this staff member’s shift has finished. The medication records for 10 residents were checked and found to be in good order. A medication round was observed and residents were given their medication sensitively and safely. Primrose Croft DS0000015237.V351090.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): 12,13,14,15 Quality in this outcome area is good. Activities in the home provide entertainment, stimulation and variety for residents. Mealtimes are relaxed and enjoyable. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There continues to be varied activities and outings for residents, details of which are prominently advertised around the home. Recent events have included a slide show of old Cambridgeshire, a summer fete, and a variety of musical entertainers. A new activities co-ordinator has recently been employed for 20 hours a week and has been working hard to find out what residents want and a number of outings have already been planned. The home has recently introduced a newsletter for residents and their visitors that gives good information about forthcoming events and staff news. Relatives commented that they were kept up to date with important issues affecting residents. One daughter wrote ‘the manager always informs me immediately of any problems or any of my mum’s needs’. Another stated: ‘they always phone me’ A number of residents and relatives raised concerns about laundry. One relative stated: ‘management of clothes and laundry is not great. No ironing is Primrose Croft DS0000015237.V351090.R01.S.doc Version 5.2 Page 13 done. Mother sometimes has other people’s clothes-even though they are all labelled’ another wrote ‘the laundry service is non-existent. On the odd occasion that the right garment gets back to the right resident, it’s completely wrecked. I do most of the washing myself now.’ Food at the home is good and residents always have a choice of what to eat The inspectors took their lunch with residents that consisted of lamb hot pot or chicken pie, followed by apple pie or chocolate roll. The food was plentiful and tasty, although was served fully plated up, thereby denying residents choice of how much and what they could eat. This practice is a little institutionalised. Three residents needed help to eat their lunch: staff assisted them sensitively; giving them plenty time to enjoy their food. Residents’ food preferences are respected and one commented: ‘I have to be careful of my diets, therefore the cook and staff always help me to get the food that suits me, and I have no complaints’ Primrose Croft DS0000015237.V351090.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): 16, 18 Quality in this outcome area is good. Residents have access to an effective complaints procedure and feel confident that their concerns will be dealt with appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents and relatives who completed the questionnaires stated that they did know how to complain if they were unhappy about the care provided. One relative wrote ‘there are plenty notices in the home about the complaints procedure and I was provided with an information pack’. Another wrote ‘any problems have been dealt with promptly’. Residents spoken to stated they felt able to complain and were confident their complaint would be taken seriously. One commented: ‘I would certainly speak to the manager if I was not treated well’. There have been three reported allegations concerning adult protection in the last year. The manager has always responded appropriately, informed relevant agencies and helped with investigations. All three concerns were unfounded. Primrose Croft DS0000015237.V351090.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): 19,20,22,25,26 Quality in this outcome area is good. Residents live in a comfortable, clean and well-maintained environment. This judgement has been made using available evidence including a visit to this service. 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. There are a number of aids and adaptations throughout the home to assist residents including grab rails, raised toilet seats and moving and handling equipment. The dementia care unit has pictorial signage to aid orientation, and a keypad entry system and a stair gate to ensure residents’ safety. However, this unit is also on the first floor of the home, thereby making it very difficult for residents to access the garden area for fresh air and natural light. Primrose Croft DS0000015237.V351090.R01.S.doc Version 5.2 Page 16 The home was clean and free from strong odours on the day of inspection and furnishings and fittings were of good quality. New television and DVDs have recently been purchased for each unit in the home. Primrose Croft DS0000015237.V351090.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): 27,28,29,30 Quality in this outcome area is adequate. Residents’ needs are met by trained staff in sufficient numbers. However staff continuity is poor and residents do not receive their care from a stable staff group who know their needs well. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels are adequate. 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 38 residents. There are three waking night staff. Residents spoken to reported that staff were available when needed, although sometimes they had to wait a few minutes for help. The home is currently reliant on agency staff to cover vacant shifts and these staff had covered 151 hours in the home the week prior to the inspection. On the day of inspection itself three of the six staff on duty were from an agency. Records viewed showed that staff receive a range of training specific to the needs of older people. Over 50 of permanent staff hold an NVQ level 2 or above, and many of the care staff are qualified nurses from their country of origin. Six staff are currently attending a dementia care course run by the local community mental health team, and the manager has recently attended a two day seminar on caring for those with dementia. The personnel files for two recently employed members of staff were viewed and showed that satisfactory references, POVA and CRB checks had been received before they began their employment. Primrose Croft DS0000015237.V351090.R01.S.doc Version 5.2 Page 18 Primrose Croft DS0000015237.V351090.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): 31,32,33,38 Quality in this outcome area is good. The management of the home is based on openness and respect, and there is an effective quality assurance system in place to gather the views of residents. Residents are protected by the home’s health and safety practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has worked at the home for a number of years. She holds the registered manager’s award and has recently undertaken further training in staff clinical supervision. Staff report her to be supportive and approachable and she is clearly committed to providing a good service at Primrose Croft. Relatives also spoke positively of her and one commented: ‘the manager is always cheerful and extremely helpful’ Procedures are in place to seek feedback about the quality of the service provided by the home. A Customer Satisfaction Survey was undertaken in Primrose Croft DS0000015237.V351090.R01.S.doc Version 5.2 Page 20 January 2007, requesting feedback from residents and their relatives about the admission procedure, staffing, care, meals, activities and the environment. 37 people responded, the majority of whom rated the home well. Regular residents’ and relatives’ meetings are also held, details of which are well advertised around the home A number of records in relation to health and safety were viewed (including gas, electrical wiring testing, hoist and lift servicing): these were all up to date and in good order. Files viewed showed that staff had undertaken training in moving and handling, infection control, food hygiene and fire safety. Cleanliness in the kitchen was good and all foodstuffs were stored correctly. Kitchen staff have recently attended training run by the Food Standards Agency and new safer working systems have been introduced in the kitchen as a result. Primrose Croft DS0000015237.V351090.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 3 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 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 3 3 3 x 3 x x 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x N/A x x 3 Primrose Croft DS0000015237.V351090.R01.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. 2. Standard OP7 OP10 Regulation 15(2)(a) 12(4)(a) Requirement Residents must be more actively involved in planning and reviewing their care The management of laundry must be improved to ensure that residents wear their own clothes at all times, and that their clothes are well cared for. Timescale of 01/01/07 not met The use of agency staff must be reduced so that residents receive their care from a stable staff group who know their needs well. Timescale for action 01/11/07 01/11/07 3. OP27 18(a)(b) 01/11/07 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 Croft DS0000015237.V351090.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Cambridgeshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Croft DS0000015237.V351090.R01.S.doc Version 5.2 Page 24 - 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. 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