Inspection on 03/05/05 for Primrose Croft

This inspection was carried out on 3rd May 2005.

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

The inspector 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 26/11/06

Primrose Croft 11/10/05

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 Cambridgeshire CB4 3EH Lead Inspector Janie Buchanan Announced 3rd May 2005 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 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service Primrose Croft Address Primrose Lane, Cambridge, CB4 3EH Telephone number Fax number Email 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 plc 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 Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7 September 2004 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 Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the home’s first inspection for the year 2005/6. It was announced. The inspector spent 7 hours at the home and interviewed four residents, three members of staff and the manager. She also took lunch with the residents. The inspector undertook a brief tour of the home, checked medication storage and viewed a range of documents. The inspector also received a total of 30 comment cards completed by residents and their relatives. What the service does well: What has improved since the last inspection? What they could do better: Full day visits to the home should be actively encouraged before residents move in so that they have an opportunity to sample daily life at the home, and also so that staff can fully assess their needs over a period of time. Residents have their names in large and colourful print on their bedroom doors in the dementia care unit but this could further be enhanced by having objects of a personal and familiar nature to the resident attached to the door to help them identify which bedroom is theirs. Individual plans of care for these residents should give more information about their history and life experiences so that staff can better understand their needs. Primrose Croft Version 1.10 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Primrose Croft Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Primrose Croft Version 1.10 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 standard(s) 1,3,5 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 detailed Statement of Purpose and Service User Guide that contain all the elements required by this standard. Both these documents have been updated since the last inspection. A copy of the most recent inspection report is available in the entrance to the home for visitors and residents to read. The manager, or one of the team leaders, assesses all prospective residents prior to their admission and the inspector viewed pre-admission assessments on all three residents’ files that she viewed. The home occasional admits residents for emergency respite care. The manager stated that, on these occasions a copy of the person’s needs-led assessment, completed by their care manager, is always obtained before they are admitted to the home. The inspector suggested that the manager invites all residents to spend a full day at the home as part their assessment process, prior to their admission. Primrose Croft Version 1.10 Page 9 This would ensure that residents’ needs could be fully assessed and also give residents a chance to experience life at the home. Primrose Croft Version 1.10 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,11 The health care needs of residents are well met with evidence of good multidisciplinary working taking place on a regular basis EVIDENCE: Every resident is registered with a local GP practice; an optical health care company visit regularly to test residents’ eyesight and a chiropodist visits every 6 weeks. A community psychiatric nurse and dietician visit regularly to offer support to residents and staff. A nutritional risk assessment is completed for each resident and their weights are recorded monthly. The manager reported that no resident currently had a pressure sore. The inspector viewed a letter written by the local district nursing team that praised staff for care that ‘has been to the highest standard’ for one of their patients at the home. The health care needs of residents were documented and monitored in their care plans and there was a record of visits by health care professionals. Residents terminal care wishes were also clearly recorded in the plans. However, care plans for those residents on the dementia care unit gave only very basic information about their personal histories and life experiences. This Primrose Croft Version 1.10 Page 11 information is crucial and must be more detailed so that staff can fully understand and meet the needs of those residents with dementia. Medication storage of controlled drugs has improved since the last inspection and medication recording was generally satisfactory, although a few handwritten additions to the MAR sheets had not been signed or dated. Staff authorised to administer medicines had received training, although no formal practical assessment of their competence was completed or documented. There was no lockable fridge available to contain medicines that require cool storage and one must be obtained. Primrose Croft Version 1.10 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 Social activities are well managed and provide stimulation and interest for people living in the home. Residents are helped to maintain good links with family and the local community. EVIDENCE: The home employs a specific activities co-ordinator for 20 hours a week and there is a busy and well-publicised activities schedule in place. One relative commented: ‘ I am very impressed with the activities available’. There are frequent outings organised for residents and forthcoming trips to Woburn Safari Park, Bedford Butterfly Park, Hampton Court Flower Show, Hunstanton and Bressingham Steam Engines are planned. A local church visits fortnightly to conduct Holy Communion and a nun visits a number of catholic residents. Relatives reported that staff are friendly and helpful towards them. The inspector viewed a sample of menus that indicated meals in the home were good, offering both choice and variety for residents. She also had lunch with the residents on the day of inspection: this was a pleasant and relaxed affair. Primrose Croft Version 1.10 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 standard(s) 16, 17,18 Complaints are taken seriously, and dealt with promptly and thoroughly. However further training must be given to all staff so they are fully aware of how to deal with adult protection concerns. 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. The inspector viewed the complaints file: all complaints were thoroughly recorded, as was action taken in their light. A copy of each complaint is sent to Excelcare’s regional office for monitoring and there is a new system in place for ensuring that all complaints are responded to within the given timescale. The Commission for Social Care Inspection has received one formal complaint about the home in the last year: the manager is currently investigating this. A number of staff have received training in adult protection and more training is planned in the near future. However, one senior member of staff showed poor knowledge of the required reporting procedures when dealing with an alleged incidence of abuse. Residents’ rights to vote are upheld at the home. The manager reported that a number of residents had received postal votes and 6 residents were planning to go to the polling station on 5th May to vote. Primrose Croft Version 1.10 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 standard(s) 19,20,22,24 Residents live in a comfortable and well-maintained environment with specialist equipment in place to promote their mobility and independence 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, a keypad entry system and a stair gate to ensure residents’ safety. A sensory room for these residents is currently being developed. Primrose Croft Version 1.10 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 The home’s recruitment and selections procedures are robust and ensure that residents are adequately protected. Training in dementia care for staff must be improved so that they have the knowledge and skills to properly look after residents. EVIDENCE: Staffing levels within the home meet minimum requirements in accordance with guidance recommended by the Department of Health and are adequate to meet the needs of residents. The home has a good recruitment and selection procedure in place: the inspector viewed a sample of personnel files and all staff had satisfactory references and CRB checks in place. Staff interviewed by the inspector reported that they had been thoroughly interviewed and confirmed that they had received a job description and employment contract. Staff training was generally satisfactory, although neither staff member interviewed on the dementia care unit had received any training in this matter, and their knowledge of the different types of dementia and person centred care was poor. 50 of staff have yet to achieved their NVQ 2 award in care as required by the standards. Primrose Croft Version 1.10 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36 The manager is competent to run the home and both staff and residents benefit from her open and supportive management style. EVIDENCE: Both staff and relatives described the manager as hardworking, committed and approachable. She has undertaken training in a number of management functions such as recruitment and selection, budgeting, managing staff sickness and disciplinary procedures. However, she is only making slow progress towards achieving the registered manager’s award. The manager actively seeks feedback about the home. There are regular and well advertised staff, residents’ and relatives’ meetings, minutes of which were viewed by the inspector. Staff meet regularly with their line manager to discuss aspects of their practice and training needs. Primrose Croft Version 1.10 Page 17 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 2 3 x STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x 3 3 3 x x 3 x x Primrose Croft Version 1.10 Page 18 no Are there any outstanding requirements from the last inspection? 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) Timescale for action The registered person shall make 1 July 2005 arrangements for the safekeeping of medicines received into the care home. A lockable fridge must obtained to accommodate medcines that require cool storage The registered person shall make 1 July 2005 arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse. All staff must be made aware of local guidleines for the reporting of alleged incidents of abuse. The registered person shall 1 October ensure that at all times suitably 2005 qualified persons are working in the care home. 50 of staff must achieve NVQ level 2 in care award. The registered person shall 1 October ensure that persons employed at 2005 the home receive training appropriate to the work they are to perform. All stff 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. . Version 1.10 Page 19 Requirement 2. 18 13(6) 3. 28 18 (1)(a) 4. 30 18 (1)(c ) Primrose Croft 5. 31 9 A person shall not manage a care home unless he has the qualifications necessary. The manager must complete the registered managers award 1 October 2005 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. 4. 5. Refer to Standard 5 7 9 9 19 Good Practice Recommendations Prospective residents should be invited to spend a full day at the home so that their needs can be fully assessed and they can experience a taste of life at the home. Residents care plans, particularly on the dementia care unit should include comprehensive information about the residents life history and personal experiences. Hand written additions to the medical administration records should be signed and dated. An assessment of competence of staff to administer medicines safely must be documented and retained on file. Objects of a personal and familiar nature to the resident should be attached to their bedroom doors on the dementia care unit so they can more easily recognise which room is theirs. Primrose Croft Version 1.10 Page 20 Commission for Social Care Inspection 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. 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