Inspection on 26/11/06 for Primrose Croft

This inspection was carried out on 26th November 2006.

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 Croft 18/09/07

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 Key Unannounced Inspection 29th November 2006 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.V321389.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.V321389.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.V321389.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th October 2005 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.V321389.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the home’s key inspection for the year 2006/7. It was unannounced. The inspector interviewed three residents, one visiting district nurse, four members of staff and the manager. A brief tour of the home was undertaken and a range of documents was viewed. The inspector also received thirteen comment cards requesting feedback about the home, completed by residents and their relatives. Most respondents were very satisfied with the overall service provided at Primrose Croft, although two were concerned about low staffing levels on the dementia care unit, and one relative felt that staff did not understand her mother’s medication needs. What the service does well: What has improved since the last inspection? What they could do better: Residents’ care plans should be reviewed monthly to ensure that their needs are monitored closely and changes picked up quickly by staff. More could be done to make the corridors in the dementia care unit varied and stimulating so that residents who spend their time wandering up and down them have places to stop and sit, and objects to see, touch and fiddle with. The strong smell of urine in this unit must also be eradicated. How residents’ laundry is handled in the home is poor and does not ensure that they wear their own clothes. This seriously compromises their dignity and must be addressed. Staff should receive supervision at least six times a year so that their working practices are assessed regularly and their training needs identified. Primrose Croft DS0000015237.V321389.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Primrose Croft DS0000015237.V321389.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.V321389.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): 1,2,3,4 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. However, this information should be made available to all residents including those who come for respite stays. 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. However, one relative whose mother had been admitted for a respite stay stated that they had not received any information about the home prior to the admission. The files for two recently admitted residents were viewed and each contained appropriate pre-admission assessments completed by the home’s manager or a care manager. Both these residents had been issued with a contract which clearly stated the terms and conditions of their stay at the home Primrose Croft DS0000015237.V321389.R01.S.doc Version 5.2 Page 9 Primrose Croft DS0000015237.V321389.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 Quality in this outcome area is adequate. Residents’ health care needs are monitored and they do have access to a variety of health care services. The home’s laundry management is poor however, and does not promote residents’ dignity. EVIDENCE: All residents who completed the questionnaire stated that they received the care and support they needed, in a way that they liked. Three residents’ plans of care were viewed. The information they contained was generally detailed, and provided staff with clear guidelines of how to meet residents’ needs. However, not all these needs had been reviewed as frequently as recommended by the standards and some of the language used in them was inappropriate and patronising, with one resident being described as ‘wellbehaved today’. Residents’ health care needs were recorded in their care plans and there was evidence that a variety of health care professionals visit the home regularly. One member of staff was observed giving residents on the dementia care unit their morning medication. This was done correctly and safely. Storage and records of medication administration were also checked on this unit and found to be satisfactory. Primrose Croft DS0000015237.V321389.R01.S.doc Version 5.2 Page 11 The home’s laundry management needs to improve. One resident told the inspector that her daughter takes quite a bit of her laundry home to wash to avoid clothing mix-ups. Another resident complained that he came home with someone else’s dirty laundry in his suitcase. A relative told the inspector that her father came home after a respite stay wearing a female resident’s underwear. Primrose Croft DS0000015237.V321389.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): 12,13,15 Quality in this outcome area is good. Activities in the home provide stimulation and interest for residents. Residents receive a healthy diet according to their needs. EVIDENCE: There continues to be varied activities and outings for residents, details of which are prominently advertised around the home. One resident praised staff for setting up games and activities and including her in them. Residents are able to receive visitors in private and there are no visiting restrictions in place. One relative commented: ‘staff go out of their way to make us feel welcome and appreciated which means so much’. Food at the home is good and residents always have a choice of what to eat. On the day of inspection itself lunch consisted of sausages in gravy, or fish cakes in parsley sauce, followed by jam sponge. One resident commented in the questionnaire: ‘the meals here are very good. ‘As I have been unable to eat certain foods the chef here has always made sure I can have an alternative to certain foods. I have always been very satisfied’ Primrose Croft DS0000015237.V321389.R01.S.doc Version 5.2 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. 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. 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 received concerned residents’ laundry and staff attitude. Both these had been investigated and the complainants responded to in writing. Residents spoken to identified the home’s manager as someone who they felt able to talk to if unhappy with aspects of their care. Staff receive training in protecting vulnerable adults. Primrose Croft DS0000015237.V321389.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,26 Quality in this outcome area is adequate. The home is generally well maintained and residents have access to a variety of areas. However, some areas of the home smelled strongly of stale urine. 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, the corridors in this unit are long and very similar looking. This unit is also on the first floor of the home, thereby Primrose Croft DS0000015237.V321389.R01.S.doc Version 5.2 Page 15 making it very difficult for residents to access the garden area for fresh air and natural light. The home was generally clean and well maintained, however there was a strong smell of urine in many areas of the dementia care unit and this must be addressed. Primrose Croft DS0000015237.V321389.R01.S.doc Version 5.2 Page 16 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. The home’s recruitment procedures ensure that residents are protected. 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. The home was fully staffed on the day of inspection and scrutiny of the duty rota showed these staffing levels to be maintained. About 50 of the home’s work force is from oversees. They have varying degrees of spoken English and one visiting nurse stated that she had recently given some continence training and was uncertain as to how much some of the overseas workers had really understood what she was saying. Staff turnover at the home is high with 9 members of staff having left since the last inspection, with over half returning home overseas. Fourteen staff are reported to hold and NVQ level 2 in care and there has been recent training in dementia care for all staff. 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.V321389.R01.S.doc Version 5.2 Page 17 Primrose Croft DS0000015237.V321389.R01.S.doc Version 5.2 Page 18 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): 31,33,36,38 Quality in this outcome area is good. The management of the home creates an open and inclusive atmosphere. Residents are protected by the home’s health and safety practices. EVIDENCE: The manager has worked at the home for a number of years and has recently completed her registered manager’s award. 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 available to speak to and is often there when I know she has the day off, she takes great care with her staff, the residents and their families’ One resident commended the manager for taking the time to lunch with them. However, one member of staff felt that the company which owns the home, Excelcare, was not responsive to ‘bottom up’ suggestions from staff. She reported that they had reduced her rate of pay despite expecting her to take on extra duties. Primrose Croft DS0000015237.V321389.R01.S.doc Version 5.2 Page 19 Staff do receive supervision from their line manager, which, they stated, was useful. However records showed that they had not been receiving it as often as recommended by the standards and two staff had not received any supervision in the last four months. Procedures are in place to seek feedback about the quality home. Questionnaires were recently sent to residents and their relatives from Excel care’s head office. The manager is awaiting their results. Regular residents’ meeting are held, details of which are well advertised around the home A number of records in relation to health and safety were viewed (including gas, fire, emergency lighting, hoist and nurse call 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. Primrose Croft DS0000015237.V321389.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 2 x x x x x 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x x 2 x 3 Primrose Croft DS0000015237.V321389.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? no 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) 12(4)(a) Requirement Residents’ care plans must be reviewed regularly The management of laundry must be improved to ensure that residents wear their own clothes at all times. All part of the home must be kept free from offensive odours Timescale for action 01/01/07 01/01/07 3 OP26 16(2)(k) 01/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 Refer to Standard OP1 OP20 OP36 Good Practice Recommendations Information about the home should be given to all prospective residents, including those who come for a respite stay. The long corridors in the dementia unit should provide a stimulating and varied environment for residents Staff should receive formal supervision at least 6 times a year. Primrose Croft DS0000015237.V321389.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office 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.V321389.R01.S.doc Version 5.2 Page 23 - 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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