Inspection on 29/08/06 for Primrose Hill

This inspection was carried out on 29th August 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 Hill 31/12/05

Primrose Hill 28/06/05

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 Primrose Hill Westwood Way Boston Spa Near Wetherby LS23 6DX Lead Inspector Pamela Cunningham Key Unannounced Inspection 11:25 29th August 2006 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 Hill DS0000033265.V306161.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 Hill DS0000033265.V306161.R01.S.doc Version 5.2 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 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) 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 DS0000033265.V306161.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The two places LD(E) are specifically for the services users named in the variation application dated 10 July 2004 31st December 2005 Date of last inspection 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 bedrooms. 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 DS0000033265.V306161.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector who was at the home for one day, from 11:25am, for a total of six hours. The inspection process consisted of speaking with the officer in charge, care staff and residents. The main purpose of this inspection was to make sure that improvements had been made in the quality of care being provided, and to assess progress on meeting any requirements or recommendations made at the last visit. The inspection year runs from April 2006 to June 2007 during which time, depending on the quality rating of the home, all care homes will have a minimum of one key inspection. Copies of previous inspection reports are available at the home or on the Internet at www.csci.org.uk. Before the visit, recent information about the home was reviewed. This included looking at the pre-inspection questionnaire, which provides the inspector with information on the working of the home, policies and procedures in place and information regarding staff and residents living at the home. The document was mailed to the home and was completed and returned on 25 August 06. The information given in the document along with other information received from the home was used to plan the inspection visit. The inspection gives an overview of the home and for some people what it is like living at Primrose Hill home. The inspectors would like to thank everyone who took the time to talk to me and express their views. During the visit, I case tracked a number of residents. This method was used to see if people were receiving the care and attention, as they required and if the care was good. During the case tracking process it was identified the home had admitted a service user in a category of care the home is not registered to care for. If the home can meet this persons needs, then the providers must apply to vary their registration. The home charges between £70:85 per week (for respite care) and £432:52 per week for those permanent residents receiving personal care. Primrose Hill DS0000033265.V306161.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Primrose Hill DS0000033265.V306161.R01.S.doc Version 5.2 Page 7 In the past, care plan documentation has not been easy to retrieve information from, however the manager and senior staff have developed a new style of care recording which will be more user friendly. She is also looking at ways for staff and visitors, including the lead inspector to be able to identify from the documentation, what care is needed, and how it is provided. Although the medication system is safe, it could be improved on by making sure all medications are signed for when given. The recruitment process needs looking at, to make sure all staff employed at the home and who work at the home and have regular contact with the residents, have a POVA check, and CRB at enhanced level 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 DS0000033265.V306161.R01.S.doc Version 5.2 Page 8 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 Hill DS0000033265.V306161.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 and 5 Quality in these outcomes is good. This judgement has been made through using available evidence including a site visit to the home. All service users have a contract of residency, know that the home will meet their needs, and have trial visits to the home prior to moving in permanently. EVIDENCE: All residents have a contract of residency, which is in the form of a booklet, however there is no information in the document, which advises what the residents have to pay for that is not covered by the fees. The home encourages pre admission visits, during which time the home gathers more information, which will enable them to produce a care plan, which addresses all the residents care needs. Since the last inspection the providers have made a decision not to provide intermediate care. Primrose Hill DS0000033265.V306161.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Quality in these outcomes is adequate. This judgement has been made through using available evidence including a site visit to the home. Care plan documentation, which showed some discrepancies, identified pre admission assessments take place except in the case of emergency admissions. Residents care needs are met but tin the past this is difficult to evidence as the information was fragmented and difficult to retrieve documented information from. Some of the documentation needed attention to certain detail, however the manager and senior staff have developed a new style of care recording, which is currently being implemented as a pilot project. The medication system is safe, however there are occasions when omissions were seen in recording medication when given. Service users are assured that the, staff will treat them and their family with dignity and respect at the time of their death. EVIDENCE: Primrose Hill DS0000033265.V306161.R01.S.doc Version 5.2 Page 11 The case tracking of lifestyle plans of three residents identified concerns. These were: Information regarding identified problems was scant. There was no evidence care plans had been signed by relatives, which gives the impression they were not involved in the care planning process. However, a daughter of one of the residents told me she had been involved in the care planning, but wasn’t interested in signing to confirm the involvement. She also said she had been asked to develop a pen picture. The officer in charge said information gathered by the care staff for the completion of pen pictures would have had to have relative involvement, as some of the residents would not have not been able to give any input. Another set of documentation identified the resident had been diagnosed as having mental health needs. A category of care the home is not registered to care for. This was discussed with the officer in charge at the time of the inspection. Certain care plans were not dated and signed, and there were two night care plans. One written on 9/8/06, and one written 23/8/06, which was 23 days, and 37 days (respectively) following admission to the home. This could and lead to inconsistencies in recording, or valuable information to be missed. Care plans should be written as soon after admission as possible. A falls risk assessment however had been completed. A summary continues to be undertaken of the lifestyle plan at the end of the month, and documented. Many of the residents are not capable of handling their own medication, where this is the case they receive adequate help from the staff. Although there were a few instances where medication had not been recorded as given, the medication system is safe. Primrose Hill DS0000033265.V306161.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14 and 15 Quality in these outcomes is good. This judgement has been made through using available evidence including a site visit to the home. Residents are encouraged to make choices regarding their own lifestyle. They are supported to maintain contact with family and friends and visitors are welcomed at the home. A good, varied and nutritious diet taking into account individual choices is provided at the home. EVIDENCE: Residents spoken to said they were allowed their visitors at any reasonable time, and were encouraged to go out with them, said they could get up and go to bed at times suitable to them, and vote at voting times. One lady said she had a postal vote. The home arranges residents’ meetings once every two months to which relatives are invited. Minutes of the meetings, which are recorded, were made available at the inspection. Primrose Hill DS0000033265.V306161.R01.S.doc Version 5.2 Page 13 It was interesting to see the chef had been invited to one of the meetings to discuss changes to the menu, and if the residents were in agreement with this. During the meetings, which are called residents consultative group meetings, information is given about any forthcoming inspections, if announced. The home has its own mini bus that takes the residents on any planned outings. Recent trips out have been made to a garden centre, and to Leeds Civic hall. The trip to Leeds Civic hall was made so that residents could take part in the judging of a garden competition, as a section of Primrose Hills garden had been entered into the competition. Residents spoken to said they had thoroughly enjoyed this even though their garden did not win a prize. Certain residents have also been away on a five day holiday to the coast. All residents spoken to during the visit said they thought the food was very good, and one lady who was visiting her mother said, ”I’ve never had a meal at the home, but have seen what it looks like, and it smells gorgeous”. Primrose Hill DS0000033265.V306161.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in these outcomes is good. This judgement has been made through using available evidence including a site visit to the home. The home has a detailed complaints and adult protection procedure which is robust and protects service users. Residents and their relatives have their view listened to, taken seriously and action is taken to resolve issues. Residents can be sure that their rights are protected and that they are safe from abuse. EVIDENCE: Any new admissions to the home, and their relatives are told about the complaint procedure, and the home keeps a complaint book. This was reviewed and it was positive to see there had been no complaints documented since the last visit. One of the residents said she had been told about the complaint procedure, but that she had never needed to complain. She said, “ the place is lovely, and the staff are so nice and helpful. You need something to do if you complain about a place like this”. One relative said, “I have visited regularly over the past three years and had never had any need to complain. It’s a comfort to know my wife is well cared Primrose Hill DS0000033265.V306161.R01.S.doc Version 5.2 Page 15 for. I have had meals here, the food is excellent, and I am always kept up to date with anything to do with the care of her”. One of the care officers attended a seminar at the Royal Armouries in Leeds in Safeguarding Adults. I was told by the officer in charge on the day of the visit that this training is to be provided in house by the trainer attached to the Adult Protection team in Leeds. Primrose Hill DS0000033265.V306161.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24, 25 and 26 were assessed. Quality in these outcomes is adequate. This judgement has been made through using available evidence including a site visit to the home. Residents live in a home that is safe, clean pleasant and hygienic and comfortable, however certain areas of the home need redecorating, and new carpets providing. EVIDENCE: The pink corridor on the ground floor, and green corridor on the top floor are looking quite shabby and need attention to décor. The carpets in the upstairs lounge are very worn and need replacing. The officer in charge said samples of carpets had been ordered for the residents to choose from, and that it is expected they would be replaced after the current school holidays. This is evidence that residents are involved in the running of the home and is good practice. Primrose Hill DS0000033265.V306161.R01.S.doc Version 5.2 Page 17 Many of the residents’ rooms were individually decorated and personalised with small articles of furniture brought with them from home when they were admitted. The home was very clean and tidy and with no hazards identified. The communal areas are very homely looking and comfortable with chairs of varying heights, footstools and occasional tables. Some residents have their own private telephones and there is a payphone for them to use. Help is available for those residents unfamiliar with using the telephone, or are unable to. There are aids to enhance mobility for those residents who are not so mobile. Wc’s are within easy reach of the lounge areas. Primrose Hill DS0000033265.V306161.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 Quality in these outcomes is adequate. This judgement has been made through using available evidence including a site visit to the home. Residents are supported and protected by robust recruitment procedures. Staffing numbers and skills ensure that residents’ needs can be met. EVIDENCE: The staff numbers were appropriate at the time of the inspection. Staff files inspected identified recruitment procedures were generally robust, however it was identified that on a couple of occasions, standard disclosures had been undertaken. All staff employed at the home and who have regular contact with residents must be subject to enhanced disclosure processes. It was also identified that the hairdresser had not been POVA checked, nor did she have any level of disclosure. Staff file inspected however were complete with details of training, supervision and appraisal. Care staff continue to make progress in NVQ training. Eight of the care staff have completed NVQ at level2, and two of the officers have Level 3 NVQ. Primrose Hill DS0000033265.V306161.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35, 36, and 38 Quality in these outcomes is good. This judgement has been made through using available evidence including a site visit to the home. The home is well managed and the manager is well able to discharge her responsibilities. Her and her senior staff offer good leadership to the care staff, which ensures the residents are protected and cared for in a correct manner. Residents’ finances are appropriately managed. EVIDENCE: The manager was not on the premises during the visit. However it was clear that the home runs as well in her absence as it does when she is there, which is a sign of good leadership. Primrose Hill DS0000033265.V306161.R01.S.doc Version 5.2 Page 20 Residents’ finances were checked and found to be in order and managed appropriately. Staff spoken to said they were receiving formal supervision, and this was certainly seen to be the case by the sight of supervision notes in personnel files. The home was seen to be safe and with no health and safety issues noted. Primrose Hill DS0000033265.V306161.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 X 3 X 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 3 X 3 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X X 3 3 X 3 Primrose Hill DS0000033265.V306161.R01.S.doc Version 5.2 Page 22 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. Standard OP9 Regulation 13(2) Requirement Timescale for action 04/12/06 2. OP19 16(2)(c) 3. OP29 19(1) The registered manager must ensure all medications are signed for at the time of dispensing. The registered provider must 01/02/07 ensure areas of the home, where identified in the main body of the report as needing attention to décor and carpets have appropriate action taken. The registered provider must 04/12/06 ensure all staff employed at the home and who have close contact with residents have a POVA check, and CRB at enhanced level. Primrose Hill DS0000033265.V306161.R01.S.doc Version 5.2 Page 23 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 Hill DS0000033265.V306161.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley 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 DS0000033265.V306161.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!