Inspection on 31/12/05 for Primrose Hill

This inspection was carried out on 31st December 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 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 29/08/06

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 Announced Inspection 31st January 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Primrose Hill DS0000033265.V272932.R01.S.doc Version 5.0 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.V272932.R01.S.doc Version 5.0 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.V272932.R01.S.doc Version 5.0 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 28th June 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.V272932.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has to carry out at least two inspections of care homes every year. The inspection year runs from April to March and this was the second inspection visit for 2005/2006. Copies of previous inspection reports are available at the home or on the Internet at www.csci.org.uk. The last inspection of the home was on 28 June 2005. This was an announced inspection carried out by one inspector who was at the home from 10.0 until 16.0. The main purpose of this inspection was to make sure that the home provides a good standard of care for the service users and to assess progress on meeting any requirements or recommendations made at the last visit. The methods used at this inspection included looking at care records; observing working practices and talking to staff, service users, relatives and to the manager. The methods used at this inspection included looking at care records; observing working practices and talking to staff, service users, relatives and to the manager. The methods used at this inspection included looking at care records; observing working practices and talking to staff, service users, relatives and to the manager. The manager, staff, residents and visitors were very helpful throughout the inspection and were happy to join in the process. Residents spoken to confirmed 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 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 comes a good second.” 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. What the service does well: Primrose Hill DS0000033265.V272932.R01.S.doc Version 5.0 Page 6 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. Although the information contained within the care plan documentation is complete, and identifies assessed needs, it is still fragmented, and needs pulling together in order that the information contained can be easily retrieved. I told the manager that I would be happy to work with her to enable the system to be more user friendly. Specific instructions however are in place where required along with appropriate risk assessments. Excellent pen pictures of the residents have been put together by the key workers, which enhance the quality of care provided. It is also 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. 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. Residents spoken to during theinspection told me they were happy with the care provided, that the food was very good, and the staff were “lovely”. One lady resident who has lived at the home for two years said “the staff couldn’t be better, and that she couldn’t be better cared for”. Another resident said he has particularly enjoyed the Christmas lunch provided at Wheelstone Prison. Members of staff spoke to said they were well supported by the manager. What has improved since the last inspection? Overhead tracking and hoist facility has been provided in room 19 and the adjoining WC. New vinyl floor covering has been laid in the upstairs dining room. All windows throughout the home have been replaced with UPVC double glazed units which has eliminated all draughts and improved the overall appearance of the outside of the home. Primrose Hill DS0000033265.V272932.R01.S.doc Version 5.0 Page 7 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 DS0000033265.V272932.R01.S.doc Version 5.0 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.V272932.R01.S.doc Version 5.0 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): 1, 3 and 6 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. All residents are assessed prior to admission to the home. The home is now providing intermediate care. EVIDENCE: The information contained within the Statement of Purpose has been amended to include reference to intermediate care. Intermediate care is provided by a team of Physiotherapists and Occupational Therapists, with input from Geriatricians from Chapel Allerton and local GP’s, who take the residents on temporary register until they are discharged home. The manager said it is likely, if the provision of intermediate care is successful, more beds will be allocated, this identifying the need for increases in staffing levels both by day and by night. Primrose Hill DS0000033265.V272932.R01.S.doc Version 5.0 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 and 11 Care plan documentation identified pre admission assessments had been done except for in the case of one emergency admission. Residents care needs are met but this was difficult to evidence as care plan documentation again was fragmented and difficult to retrieve documented information from. The medication system is robust. EVIDENCE: Care plans looked at, and chosen for case tracking, contained the needs of the residents and what tasks were required to be done in order to meet these needs. There is good evidence seen, however, important information could be missed due to the style of recording being fragmented. This was explained to the manager during the inspection, and an offer made of advice. District nursing notes have since been incorporated into the care documentation therefore giving a better picture of the holistic care provided. Primrose Hill DS0000033265.V272932.R01.S.doc Version 5.0 Page 11 The home has a self-medication policy, however there are no residents living at the home at the present time who have expressed a wish to self medicate. A summary is undertaken of the lifestyle plan at the end of the month, and documented. End of life situations are addressed sensitively with the resident and close family. Primrose Hill DS0000033265.V272932.R01.S.doc Version 5.0 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): 15 A good, varied and nutritious diet taking into account individual choices is provided at the home. EVIDENCE: The home still does not have a permanent cook, employed by them, agency cooks are still provided. I sampled the meal at lunchtime and found it to be very tasty, well cooked and presented. Residents spoken to 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. Primrose Hill DS0000033265.V272932.R01.S.doc Version 5.0 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 the following standard(s): All standards were assessed. 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. Residents are protected and feel safe living in the home. Residents are aware of the complaints procedure and how to use it. EVIDENCE: The manager said there have been no complaints since the last inspection, either in house or via the Commission. The complaint procedure is detailed and contains the timescales for the completion of the process. Serious complaints are dealt with by the Principal Unit Manager. Residents said they knew they could complain, but said they felt better talking their concerns through with a member of staff first. Primrose Hill DS0000033265.V272932.R01.S.doc Version 5.0 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 the following standard(s): All standards were assessed. The home offers a safe, well-maintained environment for the residents and provides appropriate bathing and toilet facilities. Some work on the environment has taken place. EVIDENCE: The home is decorated and furnished to a good standard throughout and there was evidence of recent decoration. There is a continued maintenance programme in place, however it was noticed that downstairs corridors would benefit from decoration. Various areas on the green corridor on the first floor level also need attention. A call system is in place 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 Primrose Hill DS0000033265.V272932.R01.S.doc Version 5.0 Page 15 them to use. Help is available for those residents unfamiliar with using the telephone. 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 available at the home to ensure the safety of residents and staff. Members of the Occupational Therapy department visit regularly to provide intermediate care, and to give advice and support to the care staff. Primrose Hill DS0000033265.V272932.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All standards were assessed. 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. There are however still only two waking night staff on night duty, which gives cause for concern, especially in the light of intermediate, care now being provided. Staff files reviewed identified recruitment procedures were robust and protect the residents. Care staff continue to make progress in NVQ training. The manager and one senior care officer has obtained the D 32 and 33 assessors award. 2 carers are undertaking level 2. There are seven staff that have completed level 2. Two senior care officers have obtained level3 NVQ and one carer is undertaking level 3. Training has also been provided in Lifestyle planning and care planning. 14 staff were provided with update manual handling training 11/03. Primrose Hill DS0000033265.V272932.R01.S.doc Version 5.0 Page 17 District Nurses are to provide staff with training on the prevention of pressure sores and complications of bed rest. 13 staff have undertaken Adult protection training, which has been facilitated by a trainer attached to Leeds Adult Protection team Primrose Hill DS0000033265.V272932.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 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. There are some practices that do not promote and safeguard the health safety and wellbeing of the people using the service. All other Health and Safety checks are undertaken. EVIDENCE: All resident accidents were recorded. Unwitnessed accidents included the time of when the resident had last been seen prior to the accident. The manager said mandatory training in manual handling is being provided, however, fire safety training is limited only to monthly fire drills being undertaken. Regulation 23 (4)(d )states The Registered Provider shall after consultation with the fire authority Primrose Hill DS0000033265.V272932.R01.S.doc Version 5.0 Page 19 (d) make adequate arrangements for persons working at the care home to receive suitable training in fire prevention. A requirement has been made. Health and Safety records were checked whereby it was identified that the nurse call system was not serviced annually by an electrician. All other health and safety checks were up to date. Primrose Hill DS0000033265.V272932.R01.S.doc Version 5.0 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 x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x x x x 2 Primrose Hill DS0000033265.V272932.R01.S.doc Version 5.0 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. Standard OP38 Regulation 23 (4)(d) Requirement The registered Provider must ensure all staff receive Fire Safety training on induction, and annually thereafter Timescale for action 30/04/06 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.V272932.R01.S.doc Version 5.0 Page 22 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.V272932.R01.S.doc Version 5.0 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. 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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