CARE HOMES FOR OLDER PEOPLE
Primrose House Primrose House Perry Hill Worplesdon Guildford Surrey GU3 3RF Lead Inspector
Lisa Johnson Unannounced Inspection 1st September 2006 09:15 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 House DS0000013751.V310120.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 House DS0000013751.V310120.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Primrose House Address Primrose House Perry Hill Worplesdon Guildford Surrey GU3 3RF 01483 232628 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) primrose.house@ntlworld.com Mrs Anne-Marie Antoinette Beeharry Mr Ahmad Issac Beeharry Mrs Anne-Marie Antoinette Beeharry Care Home 16 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (16) of places Primrose House DS0000013751.V310120.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Of the 16 (sixteen) accommodated 4 (four) may fall within the category of DE(E) The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE 19th May 2006 Date of last inspection Brief Description of the Service: Primrose House is a large house in the Worplesden district on the main road to Guildford. The home is close to a pub and the village hall. Public transport provides links to Guildford. The home is registered for sixteen older people, some of whom have mental health needs. There is a large garden to the rear of the house and parking facilities are available at the front. The weekly charges range from £400-£540. Primrose House DS0000013751.V310120.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This site visit was part of a key inspection. The site visit was unannounced and took place over twelve hours. It was carried out by Mrs. L Johnson Regulation Inspector and Mrs. A Beharry registered manager represented the establishment. The inspector spoke to five residents to gain their views on the care provided. Four resident comment cards and two relative comment cards have been received since the site visit and comments received have been reflected in this report. A full tour of the premises took place. Staff training records, staff files and policies and procedures were sampled. The inspector spoke to two members of staff. The inspector would like to thank the staff and residents for their time, assistance and hospitality during this inspection. What the service does well:
The home provides a good standard of accommodation and provides a homely environment. Resident’s bedrooms were viewed as comfortable which were decorated with a range of personal belongings. There was a pleasant garden, which is well maintained with a gazebo for the enjoyment of residents during the summer months. Residents are provided with a varied menu and are provided with choices. The inspector spoke to one resident stated, “For breakfast I can choose my own cereal and I have my own pot of tea which is presented on a tray”. During the inspection residents and staff were involved in some group games and some residents wet out for a walk with staff. On occasions there are opportunities for outings to shows. The inspector spoke to some residents to gain their views on the care provided and responses included “The staff are very nice”, “The home is nice and it is always clean”. The inspector also had the opportunity to speak to some relatives who were visiting. One relative said the service is “Homely and I am always made to feel welcome when I visit the home”. Another relative said that the home is “good”.
Primrose House DS0000013751.V310120.R01.S.doc Version 5.2 Page 6 Another relative commented, “The activities are good and the atmosphere in the home is just right”. There is an open door availability for family and friends to visit”. What has improved since the last inspection? What they could do better:
Primrose House DS0000013751.V310120.R01.S.doc Version 5.2 Page 7 At the previous site visit a requirement was made that individual care plans should be agreed and signed by residents and or their representatives. This matter has not been completed. A further requirement was made that this is completed to ensure that residents are fully involved and agree to their care plan. It was noted by the inspector that there was a fridge in the office and on examination it was noted that this fridge contained some external medication including creams, eye drops and injection ampoules, which was not locked. An immediate requirement was made that the fridge must be kept locked to ensure the health, welfare and safety of residents. On a follow up visit to the service items from this fridge had been removed and the inspector was informed that the fridge is to be disposed of. During examination of the medication administration cards the inspector noted that one individual who was prescribed paracetamol, which had been handwritten on the medication administration card by a member of staff. The member of staff had not signed the medication administration record and the card did not specify the dose or frequency. An immediate requirement was made that the all medication that is transcribed on to the medication card should be signed and dated by the member of staff who is qualified to administer medication with the dose and frequency recorded. Since this site visit this matter has been completed. One individual was receiving a medication that was secondary dispensed from the original dispensed box into a redidose container. The dose of this medication changes frequently and a written record of the required dose is recorded in the home as instructed by the visiting nurse. The recorded dose in this book did not correlate with what was recorded on the main medication administration record. The number of tablets dispensed into the redidiose container was correct. However there was no risk assessment in place for the safe administration for the secondary dispensing. An immediate requirement was made that the home should ensure that a safe system including a risk assessment should be completed for the safe administration of the secondary dispensed medication. A specialist pharmacist visited the home on 14th September 2006 to look at the storage, administration and recording of medication. Medication was stored securely for the protection of the service users. However some eye products had not been dated when they were opened and so the home could not demonstrate that they had not been in use for more then the 28 days open shelf life. An old copy of Surrey county council guidelines for medication handling was still displayed on the front of the medication cupboard. The home had a medication handling policy but this was very brief and did not provide the detail to enable staff to undertake the tasks described. Details of where to find the current pharmaceutical society guidelines for safe medication handling in care homes were left with manager. All medication was now being given to the
Primrose House DS0000013751.V310120.R01.S.doc Version 5.2 Page 8 service user directly from the original labelled container, with a clear record of the dose given. When medication was not given the reason why was not always being recorded. Whilst clear records were kept of medication given to service users there were a number of areas where the standard of record keeping needed to be improved. When a variable dosage of medicine was prescribed the actual amount given was not always recorded. When medication was discontinued there was no clear record as to who had authorised this. Receipt records were not kept for medication received in the blister packs. Further requirements were made in respect of these matters. This is to ensure that service e users are protected by the home medication administration policies and procedures. Although the home has implemented a local safeguarding adult’s procedure it was recommended that the contact detail for the local authority Social Care Team is included. The care staff undertake the cooking in the home and a recommendation was made that the home considers employing a cook so that staff can concentrate on their care duties During a tour of the service the cupboard in the corridor containing cleaning materials was unlocked. The inspector was informed that the padlock to the door was not working. An immediate requirement was made that this safety matter was addressed and that the door should be kept locked at all times. This is to ensure that the health, welfare and safety of residents is protected. During the visit a maintenance person visited the home to change the lock. At the previous visit a requirement was made that radiator covers are provided throughout the home. Some progress has been made in respect of this matter. However the covers have not been installed yet. A further requirement was made that written confirmation is provided to the Commission for social care inspection when this work is to commence. This is to ensure that the health and safety of residents is protected. 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 House DS0000013751.V310120.R01.S.doc Version 5.2 Page 9 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 House DS0000013751.V310120.R01.S.doc Version 5.2 Page 10 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): 3&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The home is able to demonstrate that pre admission assessments are obtained prior to admission to the home but needs to complete its own assessment to ensure that the home can fully meet the needs of the individual. EVIDENCE: There have been some new residents admitted to the home since the previous inspection and the file for one individual was sampled. It was evident that preadmission assessments and information was available from care managers and other health care professionals, which are obtained prior to admission to the home. The manager informed the inspector that prospective residents have the opportunity to visit the home prior to admission. Primrose House DS0000013751.V310120.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each service is provided with an individual care plan, which details the individual’s health, personal, emotional and social needs. Further work is required in ensuring that service users and/or their representatives sign individual plans where possible to ensure that they are fully involved in their process. EVIDENCE: During this visit the inspector sampled four residents files. Care plans were available for three individuals covering areas for example mobility, nutrition, sensory awareness, orientation, emotional wellbeing, religious needs and social interaction. A care plan was not present during this visit for one individual who had been recently admitted into the home. A requirement was made that this care plan should be made available to ensure that information is present as to what action the staff need to take to ensure the individuals care needs are met. Primrose House DS0000013751.V310120.R01.S.doc Version 5.2 Page 12 Other plans indicated that goal plans are regularly reviewed and evidence was available that relatives have been invited to attend reviews. Two comment cards received from relatives indicated that they were kept informed of important matters affecting their relative and are consulted about their care. However a previous requirement was made that individual plans must be agreed and signed by residents and or their representatives. This matter has not been completed and a further requirement has been made. This is to ensure that residents and their representatives are fully involved in the drawing up of their plan. Residents have access to a range of health care professionals, which includes the GP, district nurse, chiropodist and mental health specialists. One resident ha a detailed risk assessment in place in respect of smoking. However it was recommended that all documents be dated when they are signed. Staff were observed to speak to residents respectfully and in a friendly manner and their privacy was respected when carrying out personal care with doors to bedrooms and bathrooms kept shut. The medication administration systems were examined. Since the previous visit the home has made some improvement in signing the medication administration records when medication has been administered. The manager informed the inspector that two staff assists with administering medication where possible and errors. It was noted by the inspector that a fridge was present in the office and on examination it was noted that this fridge contained some external medication including creams, eye drops and injection ampoules with the fridge not being locked. An immediate requirement was made that the fridge must be kept locked to ensure the health, welfare and safety of residents. On a follow up visit to the service items from this fridge had been removed and the inspector was informed that the fridge is to be disposed of. During examination of the medication administration cards the inspector noted that one individual who was prescribed paracetamol, which had been handwritten on the medication administration card by a member of staff. The member of staff had not signed the medication administration card and the dose or frequency was not specified An immediate requirement was made that the all medication that is hand transcribed on to the medication card should be signed and dated by the member of staff who is qualified to administer medication with the dose and frequency recorded. Since this site visit this matter has been rectified. One individual was receiving one medication that was secondary dispensed from the original box into a redidose container. The dose of this medication changes frequently and a written record of the required dose is recorded in the home as instructed by the visiting nurse. The recorded dose in this book did not correlate with what was recorded on the main medication administration record. The number of tablets dispensed into the redidiose container was
Primrose House DS0000013751.V310120.R01.S.doc Version 5.2 Page 13 correct. However there was no risk assessment in place for the safe administration for the secondary dispensing. An immediate requirement was made that the home should ensure that a safe system including a risk assessment should be completed for the safe administration of the secondary dispensed medication. Since this site visit evidence was provided that this matter is now completed A recommendation was made that the manager obtains a copy of the Royal Pharmaceutical Societies guidelines for the administration of the control of medications in the home A specialist pharmacist visited the home on 14th September 2006 to look at the storage, administration and recording of medication. Medication was stored securely for the protection of the service users. However some eye products had not been dated when they were opened and so the home could not demonstrate that they had not been in use for more then the 28 days open shelf life. An old copy of Surrey county council guidelines for medication handling was still displayed on the front of the medication cupboard. The homes had a medication handling policy but this was very brief and did not provide the detail to enable staff to undertake the tasks described. Details of where to find the current pharmaceutical society guidelines for safe medication handling in care homes were left with manager. No service users held and administered their own medication. Medication was given to service users by trained and designated care staff. All medication was now being given to the service user directly from the original labelled container, with a clear record of the dose given. Whilst clear records were kept of medication given to service users there were a number of areas where the standard of record keeping needed to be improved. • When medication was not given the reason why was not always being recorded. • When a variable dosage of medicine was prescribed the actual amount given was not always recorded. • When medication was discontinued there was no clear record as to who had authorised this. • Receipt records were not kept for medication received in the blister packs. Further requirements have been made in respect of these matters. This is to ensure that service users are protected by the homes medication administration policies and procedures. Primrose House DS0000013751.V310120.R01.S.doc Version 5.2 Page 14 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): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that residents have access to a range of recreational and leisure activities and maintain links with their family/friends and the local community. Residents are supported to make choices and individual preferences are respected. Residents receive well-presented and balanced meals. EVIDENCE: Information of activities provided was displayed. Activities included for example gentle exercise, walks to the local park, card games, and reminiscence. During the inspection residents and staff were participating in a games session in the morning and in the afternoon some residents went out for a walk to the local park with staff. An activities person visits the home weekly; the home holds a church service and pets for therapy visit. Two residents spoken to confirm that they were happy with the activities on offer with one individual stating “I like to play the games of dominoes we have here”. There are occasional visits to shows. The home provides CDs and DVDs and some residents like to read the newspaper, which are ordered, by the home. One individual stated that she had seen a concert.
Primrose House DS0000013751.V310120.R01.S.doc Version 5.2 Page 15 Relatives and friends can visit without restrictions and are able to visit in private. During the visit the inspector had the opportunity to speak to some visiting relatives. One relative stated, “ The staff make you feel welcome “. Another relative confirmed that they are kept informed about changes in their relatives care. A separate sitting room is available if residents and relatives wish to have privacy. A further comment-received form a relative indicated that the activities in the home are just right. Residents are provided with the opportunity to bring in personal possessions into the home, which was seen in display in their bedrooms. Two residents Spoken to stated that are provided with choices with regard to their meals with one individual confirming “I can choose my cereal for breakfast and I have my own pot of tea which is presented on a tray”. Another individual said “ I can have cooked breakfast if I want it”. The lunchtime meal was observed which was well presented and well balanced. Fruit was available for residents to have plus food cupboards and freezers were well stocked. Refreshments were offered during the day with tea and cake offered in the afternoon. The manager informed the inspector that the menus are to be reviewed and that all residents are to be consulted individually in respect of their preferred options. Primrose House DS0000013751.V310120.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives have access to an effective complaints procedure and their views are listened to and acted upon. Policies and procedures are in place, which protects residents from abuse. EVIDENCE: Since the previous site visit the home has amended and updated the complaints procedure, which was seen on display in the hallway. No complaints have been received since the previous site visit. During the visit the inspector received a number of positive comments from residents and relatives about the care they were receiving. Comments included. “The staff are very good”, the staff are nice and “The house is very homely and always clean”. Two comment cards received from relatives indicated that they were aware of the homes complaint procedure and were satisfied with the overall care provided. “One relative commented, “We have been very pleased by the care and attention staff in the home have given”. During the visit one individual raised an issue with the inspector and this matter was referred following the local authority safeguarding adult’s policies and procedures. Safeguarding adult policies and procedures were present in the home and staff training records were sampled which concluded that all staff are receiving adequate training in safeguarding adults. One member of staff spoken to confirmed that the manager had brought to her attention the procedures to follow.
Primrose House DS0000013751.V310120.R01.S.doc Version 5.2 Page 17 A recommendation was made that the contact details for the local authority Social Care Team should be added to the homes local policy. Primrose House DS0000013751.V310120.R01.S.doc Version 5.2 Page 18 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, 23, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well maintained with some minor redecoration needed in some areas. Resident’s bedrooms were viewed as comfortable. Residents live in comfortable surroundings, which is clean and hygienic ensuring that residents have a pleasant home to live in. EVIDENCE: A full tour of the premises was undertaken with the service providing a homely atmosphere. The home was well maintained and pleasantly furnished The garden was well maintained with a gazebo in place and is accessible for residents to use in the summer. Improvements have been made to the front of the house and a number of windows have been replaced. Toilets were accessible to the lounge and toilets and were clearly labelled with pictures to assist residents. There is a pleasant conservatory, which overlooks the gardens. A television and a portable air conditioning unit was in available with a number of residents were observed to be enjoying this area as a place to sit.
Primrose House DS0000013751.V310120.R01.S.doc Version 5.2 Page 19 The home employs an ancillary member of staff and the home was observed cleaned to a good standard and was hygienic. Separate laundry facilities were available which were adequately maintained. The kitchen was clean and well maintained with appropriate food storage and temperature monitoring in place. Primrose House DS0000013751.V310120.R01.S.doc Version 5.2 Page 20 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, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing levels were sufficient to meet the needs of residents. The home must ensure that at least fifty percent of staff have completed National Vocational Qualifications. Residents are protected by the homes recruitment practices. On the whole residents were in the safe hands of the staff that were competent and trained to do their jobs. EVIDENCE: During the inspection there were three members of staff on duty and the duty rota indicated that three members of staff during the day and two members of staff during the evening. One waking and one sleep- in member of staff are provided at nighttime. The home also employs an ancillary member of staff. Care staff undertake the meal preparation in the home. It was recommended that the home should consider employing a cook so as not to distract care staff away from their care duties. The manager confirmed to the inspector that she has been advertising for a cook but this has not been successful. The home is also arranging to appoint a deputy manager. A training schedule is maintained for each member of staff. Two training schedules were sampled which indicated that staff have received up to date mandatory training including food hygiene, first aid with training booked for all staff for fire awareness and medication. Induction training is provided which is
Primrose House DS0000013751.V310120.R01.S.doc Version 5.2 Page 21 linked to skills for care standards. All staff are receiving up-to-date training in safeguarding adults. Other training attended included risk assessment, care planning and dementia awareness. Progress has been made in respect of a number of staff obtaining and completing National Vocational Qualifications. However fifty percent of staff have not yet fully obtained the qualification. A further requirement was made that this is achieved to ensure that residents are supported by appropriately qualified staff and are in safe hands Two staff personal records were sampled POVA first checks and police checks were completed for new staff. Other information required was also available on the files. Primrose House DS0000013751.V310120.R01.S.doc Version 5.2 Page 22 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 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager holds appropriate qualifications and is experienced to manage the home. The home is able to demonstrate that quality assurance systems have been implemented. The financial interests of residents are protected. Twohealth and safety issues need addressing to ensure the health, welfare and safety of residents. To ensure that the home is run in the best interest of residents the management need to take action to meet the requirements made during the last site visit and those identified as part of this visit. EVIDENCE: The registered manager holds nursing qualifications and the Registered Managers Award and is experienced with working with older people. Staff meetings are held which were sampled.
Primrose House DS0000013751.V310120.R01.S.doc Version 5.2 Page 23 The home carries out occasional residents meetings and quality assurance questionnaires have been updated for relatives to complete. There are a range of policies and procedures available. However it is required that policies are regularly reviewed and updated with a read and sign system in place for all new policies and procedures to ensure that staff have confirmed their understanding. Some monies are maintained by the home on behalf of residents. Records are maintained of any expenditure which is documented with receipts maintained. The fire records were examinined, which indicated that a fire drill was updated and fire alarms were checked weekly. A legionella certificate was in place. The accident book was sampled with records adequately maintained. During a tour of the service the cupboard in the corridor containing cleaning materials was unlocked. The inspector was informed that the padlock to the door was not working. An immediate requirement was made that this health and safety issue was addressed and that the door should be kept locked at all times. This is to ensure that the health, welfare and safety of residents is protected. During the visit maintenance person visited the home to change the lock with this matter having now been resolved. At the previous visit a requirement was made that radiator covers are provided throughout the home. Some progress has been made in respect of this matter. However the covers have not been installed yet. A further requirement was made that written confirmation is provided to the Commission for social care inspection when this work is to commence. This is to ensure that the health and safety of residents is protected. Primrose House DS0000013751.V310120.R01.S.doc Version 5.2 Page 24 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 X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X 3 X X X 3 X 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X 2 Primrose House DS0000013751.V310120.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15(1) (2)(a) Requirement a) The registered person must ensure that a care plan for one individual is made available in the home. Timescale for action 01/11/06 2 OP9 13(2) 17(1)(a) b) The registered persons must ensure that care plans are agreed and signed by residents and/or their representatives where residents are unable to sign, this must be recorded (with the reason) in the individual care plan. (Previous requirement 19/07/06 not met) a) The registered person 30/09/06 must ensure that clear and comprehensive policies and procedures for the receipt, recording, storage, safe handling, administration, self-administration and disposal of medicines, specific to the home must be produced. b) Complete records must be kept of all medication received into the home from whatever Primrose House DS0000013751.V310120.R01.S.doc Version 5.2 Page 26 source. C) Complete and accurate records must be kept of all medication administered or not administered together with the reason why. When variable doses of medication 3 OP28 18(1) The registered person must ensure that at least fifty percent of care staff have obtained National Vocational Qualifications. (Level 2). (Previous requirement 19/08/06 not met) The registered persons must ensure that staff had read and signed any new policies and procedures that are introduced The registered person must ensure that covers are provided to those radiators in the home that present a risk to service users. Risk assesments must be completed in respect of this requirement and the schedule of work prioritised accordingly.(Previous requirement 07/09/06 not met) 01/12/06 4 OP33 18(1) 01/12/06 5 OP38 13(4)(a) 07/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 2 4 Refer to Standard OP8 OP9 Good Practice Recommendations It is recommended that all documents are dated when they are reviewed. The registered manager should consider including a photograph of each resident with the medication
DS0000013751.V310120.R01.S.doc Version 5.2 Page 27 Primrose House administration records. 5 OP9 It is recommended that the manager obtain a copy of The Royal pharmaceutical Societies guidelines for the administration and control of medicines in the home. The manager should consider employing a cook in the home 6 OP27 Primrose House DS0000013751.V310120.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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