Inspection on 28/06/05 for Primrose Hill

This inspection was carried out on 28th June 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 Hill 29/08/06

Primrose Hill 31/12/05

Primrose Hill 30/11/04

Primrose Hill 28/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Abbey The

Grayling

The Cornerstone

John Street Nursing Home

Pennine Camphill

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

CARE HOMES FOR OLDER PEOPLE Primrose Hill Westwood Way Boston Spa Near Wetherby LS23 6DX Lead Inspector Kathleen Firth Unannounced 11.00am 28th JUNE 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 Hill 20050628 Primrose Hill Un Stage 4 S33265 V229560.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Primrose Hill Address Primrose Hill, Westwood Way, Boston Spa, Near Wetherby, LS23 6DX 01937 844635 01937 844635 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) Leeds City Council Department of Social Services Mrs Susan Frances Renshaw Care Home 32 Category(ies) of Learning disability over 65 years of age (2), Old registration, with number age, not falling within any other category (32) of places Primrose Hill 20050628 Primrose Hill Un Stage 4 S33265 V229560.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 01/12/04 Brief Description of the Service: Primrose Hill Care Home is situated in the rural village of Boston Spa, near Wetherby. The home is operated by Leeds City Council and is registered to provide care for 32 residents. There is a bus stop close to the home and buses run every half hour into Leeds city centre. There are houses and schools close to the home. Accommodation at the home is on two floors in single rooms. The main dining room is on the ground floor, with a smaller one on the first floor. There are a number of lounges offering comfortable areas for the residents to sit. The bathrooms and toilets are located throughout the home convenient to the communal rooms and bed rooms. The local shops, public houses and churches are all within walking distance of the home. Car parking is limited due to other services operating from adjacent buildings. Primrose Hill 20050628 Primrose Hill Un Stage 4 S33265 V229560.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over five hours by one inspector on Tuesday 28th June 2005. The inspector looked round the building, spoke with residents, staff, management and visitors, examined residents’ records including care plans, menus, staff rosters, Statement of purpose and the residents’ guide. The manager, staff, residents and visitors were very helpful throughout the inspection and were happy to join in the process. Seventeen residents, four staff members and four visitors were all spoken to. What the service does well: Residents all have a comprehensive care plan in place with their needs clearly identified along with the tasks needed to be done in order for these needs to be met. Very specific instructions are in place where required along with appropriate risk assessments. Staff have obtained excellent pen pictures of the residents and have recorded where anyone has not wanted to talk to them about the past. Regular staff meetings and supervision sessions are in place and communication within the home is good. Residents said that they are able to go to bed/get up at the times they choose and are able to go out with family and friends or have them visit without restrictions. Family and friends are able to eat with the residents if this is their choice. All of the residents spoken with said that they are well looked after and that staff respect their privacy and dignity. Everyone said that they feel able to speak to the manager or staff if they have any concerns or worries. One lady made the comment that ‘It isn’t home but it is good.’ Most people are happy with the meals and said that there is an alternative offered if they do not like what is on the menu. There is a commitment to training and staff confirmed that they are able to access relevant courses. All staff at the home have completed or are working on an NVQ (National Vocational Qualification). Primrose Hill 20050628 Primrose Hill Un Stage 4 S33265 V229560.doc Version 1.30 Page 6 What has improved since the last inspection? 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. Primrose Hill 20050628 Primrose Hill Un Stage 4 S33265 V229560.doc Version 1.30 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 Hill 20050628 Primrose Hill Un Stage 4 S33265 V229560.doc Version 1.30 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, 2, 3, 5 People are able to make an informed decision about the home from the written information they receive and what they see when they visit the home. EVIDENCE: A copy of the Statement of Purpose and Residents’ Guide given to all prospective residents was seen, and found to contain sufficient information to help the person to make an informed choice about the home. Staff go out and assess prospective residents and these were seen to be very comprehensive. They contained sufficient information for staff to know what the needs of the people were and if these could be met at the home. Social Work assessments were seen in the files. All prospective residents are invited to look round the home and spend some time talking to residents and staff. Residents said that they had done this and found it to be useful. Families and relatives are also welcome to look round if they choose to do so. Primrose Hill 20050628 Primrose Hill Un Stage 4 S33265 V229560.doc Version 1.30 Page 9 A Licence Agreement containing the terms and conditions of the services offered is given to all residents on admission to the home. This was seen to contain all the necessary information to make sure that people know what they can expect from the home and what is expected from them. Primrose Hill 20050628 Primrose Hill Un Stage 4 S33265 V229560.doc Version 1.30 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, 10 Staff are aware of the residents’ needs and there is good communication amongst the staff group. Residents are treated with dignity and their privacy maintained at all times. EVIDENCE: Care plans looked at detailed the needs of the residents and what tasks were required to be done in order to meet these needs. The plans were clear, concise easily understood and contained healthcare, personal, religious, social and dietary needs. Very specific instructions were recorded in the files where appropriate. Risk assessments were in place alongside the coping strategies. Evidence was seen that the care plans are reviewed and updated on a regular basis. The preferred activities of the residents were not recorded in all of the files and there were slight inconsistencies in what was recorded. Evidence was seen that residents or their family are involved in drawing up the care plans. Residents said that they are treated with respect and their privacy and dignity are maintained at all times. GP, District nurses, Chiropodists, Optician and Dentists visits are all clearly recorded with the reason for the visit and any actions required following it. The manager said that the home receives excellent support from the local healthcare teams and nothing is too much Primrose Hill 20050628 Primrose Hill Un Stage 4 S33265 V229560.doc Version 1.30 Page 11 trouble for them. The nurses are always willing to offer assistance and give information to the staff. If a resident wishes to remain at the home until their death a decision is made with the healthcare team to make sure that their needs can be met. None of the permanent residents at the home manage their medication but the home has a good medication policy and procedure in place to do this. The home uses the Boots monitored dosage system and all staff have received medication protocol training. All records were seen to be correctly maintained and up to date. The way that the homes stores and orders the medication was seen to meet the required standard. Primrose Hill 20050628 Primrose Hill Un Stage 4 S33265 V229560.doc Version 1.30 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, 14,15 Residents are encouraged to be part of the decision making process and make choices about their lifestyle. They are supported to maintain contact with family and friends. Visitors are welcomed at the home at any time. A good, varied and nutritious diet taking into account individual choices and needs is provided at the home. EVIDENCE: Resident meetings are held on a regular basis and people said that they feel able to voice any ideas they may have and are listened to. Residents are free to come and go as they wish providing this is all recorded in the care plan. People confirmed that they go out with and visit family and friends. They also confirmed that they can go to bed and get up at the times they choose. Visitors said that they always feel welcome at the home and that staff keep them informed. They also feel able to speak to the manager and staff at any time if they have any concerns. Residents confirmed that the meals at the home are very good and one lady said the food was of excellent quality. There is always a choice of meal offered. People usually use the two dining areas to eat meals and the staff offer any support required to be able to eat the meal. The home operates a two weekly menu and a decision has just been taken to swap the warm sweet to the evening meal and a cold one to lunchtime. This is for a trial basis and Primrose Hill 20050628 Primrose Hill Un Stage 4 S33265 V229560.doc Version 1.30 Page 13 will be reviewed after one month. Regular weight checks are made and recorded in individual files. There are number of activities offered at the home including trips out, garden games, dominoes cards and bingo. The residents go out for pub lunches or a drink in the evening whenever staffing numbers allow. Most people join in with the activities but are able to choose not to if this is their preference. The Salvation Army visit the home on a monthly basis and the Church of England vicar holds a monthly communion service. Ministers from other denominations visit individual residents. Primrose Hill 20050628 Primrose Hill Un Stage 4 S33265 V229560.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17,18 Residents and their relatives have their views listened to, taken seriously and action is taken to resolve issues. Residents have their rights protected and are protected from abuse. EVIDENCE: The appropriate policies and procedures were seen to be in place and the manager confirmed that Adult Protection training has been organised for all staff. Adult Protection is talked about in the induction process and the manager felt that staff have enough knowledge to recognise the signs and symptoms of abuse. A copy of the complaints procedure is displayed on the notice board at the home and residents receive their own copy. Residents and relatives spoken to confirmed that they feel able to speak to staff if they have any concerns and that they are dealt with quickly and appropriately. All residents were able to vote at the recent election except on lady whose voting paper did not arrive. This has already been sorted out for the next time. Residents and families are aware that they can have access to their records. Primrose Hill 20050628 Primrose Hill Un Stage 4 S33265 V229560.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21, 24, 26 The home offers a safe, well-maintained environment for the residents and provides appropriate bathing and toilet facilities. EVIDENCE: The home is decorated and furnished to a good standard throughout and there was evidence of recent decoration. There is a maintenance programme in place. A call system is available in all areas of the home and residents have easy access throughout the home and gardens. The bedrooms are large and airy with pleasant outlooks over the garden areas. Residents are encouraged to bring their own possessions with them and evidence was seen that they are enabled to personalise their own rooms. Some residents have their own private telephones and there is a payphone for them to use. There are sufficient toilets near to the communal areas to ensure easy access for the residents. Soap and towels are available in all of the toilet areas and the water is at the correct temperature. Assisted bathing facilities are Primrose Hill 20050628 Primrose Hill Un Stage 4 S33265 V229560.doc Version 1.30 Page 16 available at the home to ensure the safety of residents and staff. Two members of the Occupational Therapy department were visiting at the time of the inspection to assess for various pieces of equipment for the residents’ use. The laundry has just been decorated and is suitable for its purpose. There is a sluicing washing machine in use. The home employs someone to work in the laundry that deals with all aspects of the work involved. There is a control of infection policy in place. No hazards were seen that could cause problems for residents, staff or visitors. The accident records were seen and were maintained correctly with only one resident having needed to attend the accident and emergency department in the last twelve months. Primrose Hill 20050628 Primrose Hill Un Stage 4 S33265 V229560.doc Version 1.30 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 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 Residents are supported and protected by the recruitment procedure that is in place. Staffing numbers and skill mix ensure that the residents’ needs can be met. EVIDENCE: The staff numbers were appropriate at the time of the inspection and residents and staff were able to confirm that this is the normal way of working. Some said that they could do with extra staff but the manager tries to cover sickness where possible. This sometimes means using agency staff but the manager said that they try to send the same staff to ensure continuity of care for the residents. Staff rosters confirmed that sufficient staff are rostered to work on any shift. Regular staff meetings are held where staff say they are able to raise issues, concerns that they may have. Staff also receive regular supervision with recorded notes. Recruitment is carried out to comply with equal opportunities and two written references plus CRB (Criminal Records Bureau), POVA (Protection of Vulnerable Adults), Visa and work permit checks are made before staff are allowed to start work. Staff files were seen to contain the necessary documentation. Training takes a high priority at the home and all staff are involved in NVQ at varying stages. The home uses an excellent induction workbook for staff to work through. The induction course is TOPPS recognised leading onto the foundation course and then NVQ. Staff receive emergency aid training and are made aware of their own and colleagues roles and responsibilities. Primrose Hill 20050628 Primrose Hill Un Stage 4 S33265 V229560.doc Version 1.30 Page 18 Primrose Hill 20050628 Primrose Hill Un Stage 4 S33265 V229560.doc Version 1.30 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 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, 33, 35, 36, 38 The home is well managed, the interests of the residents are seen as very important to the manager and staff and are safeguarded at all times. EVIDENCE: The manager has many years’ experience working in residential care for older people and has completed the Management Charter Initiative. She is due to start work on the registered manager’s award in August. Staff and residents said that she offers good support to them and they all feel able to approach her if they have any concerns/worries. Staff receive supervision on a regular basis. Residents meetings are held every two months with everyone invited to attend including people receiving respite care. Minutes of the meetings are produced and a copy was seen. Recently residents have made adverse comments about the meals and put forward ideas of their own, and some of these have been Primrose Hill 20050628 Primrose Hill Un Stage 4 S33265 V229560.doc Version 1.30 Page 20 put into practice after consultation with the chef e.g. serving a hot pudding at lunchtime and a cold sweet at the evening meal. There is a plan to hold a relatives meeting in the near future although the last one was poorly attended. Some residents manage their own finances and the financial records kept on behalf of residents were seen to be maintained in a correct way by the manager. There is an awareness of health and safety in the home and all staff take responsibility for this and receive training in this area. The manager is trying to make sure that there is a staff member trained in first aid on duty at any time. Primrose Hill 20050628 Primrose Hill Un Stage 4 S33265 V229560.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x 3 x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 x 3 x 3 3 x 3 Primrose Hill 20050628 Primrose Hill Un Stage 4 S33265 V229560.doc Version 1.30 Page 22 yes 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 OP27 Regulation 18(1) Requirement The registered provider must make sure staffing levels in the home are appropriate in terms of numbers and skill mix to meet the needs of the residents. (Previous timescale of Decemeber 2004 not met). Timescale for action 30.09.05 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. Refer to Standard 37 Good Practice Recommendations The registered manager should take steps to make sure that care plans contain all the necessary information and are consistent. Primrose Hill 20050628 Primrose Hill Un Stage 4 S33265 V229560.doc Version 1.30 Page 23 Commission for Social Care Inspection Aire House Town Street Leeds LS13 1HP 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 Hill 20050628 Primrose Hill Un Stage 4 S33265 V229560.doc Version 1.30 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. 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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