CARE HOMES FOR OLDER PEOPLE
Primrose House Primrose House Perry Hill Worplesdon Guildford Surrey GU3 3RF Lead Inspector
Lisa Johnson Unannounced Inspection 26th September 2005 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 House DS0000013751.V251940.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 House DS0000013751.V251940.R01.S.doc Version 5.0 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.V251940.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE Of the 16 (sixteen) accommodated 4 (four) may fall within the category of DE(E) 7th July 2005 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. Primrose House DS0000013751.V251940.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second inspection carried out in 2005/2006. One inspector carried out the unannounced inspection over four and half hours. The focus of the inspection was to review the requirements made at the last inspection and to look at other key standards. A tour of the premises took place and care plans, policies and procedures and other documents were sampled. The inspector spoke to four residents who live in the home. The inspector also spoke to two members of staff. The inspector would like to thank the residents and staff for their cooperation in carrying out this inspection. What the service does well: What has improved since the last inspection?
Primrose House DS0000013751.V251940.R01.S.doc Version 5.0 Page 6 A requirement was made at the previous inspection that the registered manager obtains an updated copy of the local protection of vulnerable adults policy. This has now been completed. A broken shaver point in the bathroom has been removed and a sink edge in one of the bedrooms has been repaired. A requirement was made at the last inspection that all staff must receive formal supervision at least six times a year. The registered manager was unavailable during this inspection and records were locked away. However two members of staff spoken to confirm that they had received a recent one to one meeting with their manager and records were maintained of this discussion. What they could do better:
There was some outstanding action required from the previous inspection. Requirements were made at the last inspection in respect of improvements in the decoration of the bathroom, dining room and upstairs corridor and that an action plan should be completed indicating the timescales for completing the internal redecoration. This has not been completed and further action has been required by the Commission for Social Care Inspection to ensure this work is completed. A requirement was also made that a risk assessment must be completed to identify all the hazards that may have an effect on the health, welfare and safety of service users in the home during the internal redecoration work. The homes complaint procedure was seen and has not been amended to state that the Commission for Social Care can be contacted at any stage of a complaint and no copy of the procedure was present in the homes statement of Purpose. A further requirement was made that the complaints procedure is amended and that a copy is maintained as part of the statement of Purpose to ensure that residents and their relatives/friends have the information they require and that they are confident that complaints will be listened to. The homes medication and administration records were sampled and there were occasional gaps where medication was not signed for. A requirement was made that all gaps in signing are followed up. A further requirement was made that a list of all staff who have been trained and who are able to administer medication must be made available with the medication and administration records to ensure that residents health, wellbeing and safety is protected by the homes policies and procedures for dealing with medicines and a recommendation was made that a photograph is included with individuals medication and administration records. Care plans were detailed and comprehensive, however individuals must sign their agreed care plan wherever possible and/or representative. A further
Primrose House DS0000013751.V251940.R01.S.doc Version 5.0 Page 7 requirement was made that a photograph should be included with the care plan. A policy and procedure was in place for dying and death, which was observed by staff. A recommendation was made that the registered manager should consider recording each residents personal wishes about what they want to happen and to provide instructions about the formalities to be observed including the individuals family and friends (if the resident wishes this) in the individual plan. A recommendation was made that the registered manager should consider implementing a schedule to record dates of staff supervision. Hand towels were not provided in one downstairs toilet and a requirement was made that all communal toilets must be provided with towels for hand drying. 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.V251940.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 House DS0000013751.V251940.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 The home needs to provide an updated copy of the homes complaint procedure to ensure that prospective residents have the information they need to make an informed choice about where to live. EVIDENCE: The homes Statement of Purpose was sampled and a copy of the complaints procedure was not present. A requirement was made that an amended copy of the procedure is made available with the statement of purpose to ensure that residents and their relatives/friends have the information they require. Primrose House DS0000013751.V251940.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): 7,9 &11 The health and personal care needs of residents were being met and set out in an individual plan of care. The home must adhere to the homes medication policy so that resident’s health, welfare and safety is protected by the homes policies and procedures for dealing with medicines. Policies and procedures for handling death and dying are in place and observed by staff. EVIDENCE: Each individual is provided with a care plan which covered health, emotional and social needs. Risk assessments were in place for moving and handling. Care plans were reviewed regularly. However a requirement was made that the individual should sign their agreed plan wherever able and/or representative if possible. A further requirement was made that a photograph should be included in each plan. Medication and administration records were sampled; there were occasional gaps in staff not signing the medication records. A requirement was made that any gaps in administration must be followed up. A further requirement was made that an updated list of all staff who are trained to administer medication must be made available with the medication and administration records to
Primrose House DS0000013751.V251940.R01.S.doc Version 5.0 Page 11 ensure the health, wellbeing and safety of residents. Medication was stored adequately and the home receives visits from the pharmacist. A policy and procedure was in place for death and dying and was observed by staff. A recommendation was made that the registered manager should consider recording each resident’s wishes in the individual plan. Primrose House DS0000013751.V251940.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): 12 & 15 Residents were offered a range of recreational and social activities. Residents were offered a well balanced diet and choice of meals EVIDENCE: The home provides a range of leisure and social activities if residents wish to join in. At the time of the inspection a church service was taking place with the local vicar in attendance and residents were clearly enjoying singing the hymns. Residents are supported to go out for walks and occasional outings. Some residents were reading daily newspapers, which are delivered. The lunchtime meal was seen and was of a good standard and nutritious. Choices were available and this was seen when residents were requesting alternatives. The mealtime was unhurried and relaxed. One resident was able to have her meal in her room. One member of staff stated that some residents like to help to lay the tables for meals. Primrose House DS0000013751.V251940.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): 16, 17 & 18 The homes complaints procedure needs to be accessible and updated to ensure that residents and their relatives have the required information and are assured that their concerns will be listened to. Policies and procedures were in place to protect the legal rights of residents. Policies and procedures were in place to ensure that residents are protected from abuse. EVIDENCE: At the previous inspection a requirement was made that the complaints procedure was updated to state that the Commission for Social Care Inspection can be contacted at any stage of a complaint if the complainant wishes to do so. This has not been completed and this has been made a further requirement. Any complaints received are logged in the homes communication book and staff spoken to state that they deal with any issues as soon as they arrive. A recommendation was made that a separate record book is maintained of all complaints received and includes any action taken. Policies and procedures were in place that protects the rights of residents. The home has adequate policies and procedures in place that protect individuals from abuse. Primrose House DS0000013751.V251940.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): 19, 20, 22, 25 & 26 The home is clean and hygienic. Improvement in the decoration and maintenance of the bathroom, dining room and corridors will ensure that residents will have an improved and more comfortable place to live. EVIDENCE: A requirement was made at the previous inspection that the upstairs bathroom was redecorated and that the registered manager supplies the Commission for Social Care inspection with timescales as to when the redecoration work to the dining room and upstairs is to be completed. Staff spoken to stated that they are expecting the work to be undertaken soon and quotes for the work have been completed. These requirements remain unmet and further action has been required as a result of this inspection. A further requirement has been made that the dining room and upstairs corridor must be repainted and that the Commission for Social Care must be informed of time scales. This is to ensure that residents have well-maintained and comfortable communal areas to live in. Tiles must be replaced on the back ledge of a bath in the en-suite bathroom upstairs and two windows were found in need of repair in the
Primrose House DS0000013751.V251940.R01.S.doc Version 5.0 Page 15 laundry room and an upstairs bedroom as they were found lodged open. This maintenance must be carried out to ensure that residents live in a safe and comfortable environment. The home provides specialist equipment to maximise resident’s independence including assisted bathing, raised toilet seats and rails. The home was clean and hygienic and free from offensive odours. Laundry areas are sited appropriately. Primrose House DS0000013751.V251940.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): 27 The staffing levels were adequate to meet the needs of the residents. EVIDENCE: At the time of the inspection there were three staff on duty plus an ancillary member of staff who is responsible for the cleaning in the house. Three staff were on duty on the afternoon shift. Primrose House DS0000013751.V251940.R01.S.doc Version 5.0 Page 17 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): 33, 36, 37 & 38 The registered manager should consider implementing a schedule to record the dates of all formal supervision with staff. Records were maintained adequately. The registered manager must complete a risk assessment to identify all hazards that may be detrimental to the health, welfare and safety of residents when the redecoration work to the house is being carried out. EVIDENCE: The home has implemented quality assurance questionnaires and holds residents meetings. A recommendation was made that these are updated and consideration should be given to updating resident meetings. A requirement was made at the previous inspection that all staff must receive formal supervision at least six times a year. Two staff spoken to confirmed that they have received a recent one to one meeting with their manager, which was documented. As the registered manager was unavailable for this inspection supervision records could not be accessed and a recommendation was made that the registered manager should consider implementing a schedule for
Primrose House DS0000013751.V251940.R01.S.doc Version 5.0 Page 18 dates of all staff supervision, which is signed by the staff member to confirm that a meeting has taken place. The kitchen was visited and found to be clean and hygienic and food storage and fridge temperatures recorded appropriately. However at the previous inspection a requirement was made that hand towels were placed in a downstairs toilet and these were still not available. A further requirement was made that all communal toilets in the home must be provided with disposable paper towels for drying hands to protect the health and welfare of residents and staff. Records were maintained securely and record keeping procedures were available. A requirement was made at the previous inspection that a risk assessment was completed to identify hazards when the redecorating work is completed and this has not been completed. A further requirement was made that this is to be completed and that a copy is made available to the Commission for Social Care Inspection to ensure the well being and safety of residents. Primrose House DS0000013751.V251940.R01.S.doc Version 5.0 Page 19 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 2 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 2 2 X 3 X X 2 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X 2 3 2 Primrose House DS0000013751.V251940.R01.S.doc Version 5.0 Page 20 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 OP7 Regulation 15 (2) (a) Requirement The agreed care plan must be signed by the resident where ever possible and/or representative (if any) A photograph must be made available of all residents with their care plan. An up-to-date list must be supplied of all staff who are trained to administer medication must be made available with the medication and administration records. An audit trail must be implemented to follow up any gaps in signing on the medication and administration records. The complaints procedure must be amended to state that the Commission for Social Care inspection can be contacted at any stage of a complaint. (Previous timescale of 7th August 2005 not met) The complaints procedure must be made available in the Statement of Purpose. The upstairs bathroom must be
DS0000013751.V251940.R01.S.doc Timescale for action 26/12/05 2 3 OP7 OP9 17 (1) (a) Sch 3 13(2) 26/11/05 14/10/05 4 OP9 13(2) 14/10/05 5 OP16 22(7) 14/10/05 6 7 OP5 OP19 4(1)(c) Schedule1 23 (2) (d) 14/10/05 07/10/05
Page 21 Primrose House Version 5.0 8 OP19 23 (2) (b 9 OP19 13 (4) (c) 10 OP 19 23 (2)(b) 11 OP19 23(2)(d) 12 OP38 16 (j) redecorated to ensure that residents have comfortable and well-presented communal rooms to use. The window in the laundry room and in the upstairs bedroom must be repaired to ensure that residents live in a wellmaintained environment A risk assessment must be completed to identify all the hazards that may be detrimental to the health, welfare and safety of residents when the internal redecoration work is being carried out in the home (Previous timescale 7th September 2005 not met). The bath edge in the upstairs ensuite bathroom must be repaired to ensure the comfort of residents. The dining room and upstairs corridor must be redecorated and an action plan must be implemented to identifying the time scales of this work and this must be made available to the Commission for Social Care Inspection. (Previous timescale of 7th September not met) The registered manager must provide disposable paper towels in all of the communal toilets to protect the heath and wellbeing of service users and staff. 26/10/05 26/10/05 26/10/05 26/10/05 07/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations
DS0000013751.V251940.R01.S.doc Version 5.0 Page 22 Primrose House 1 2 3 4 5 Standard OP 33 OP 9 OP 11 OP 16 OP 36 The registered manager should consider increasing the frequency of residents meetings and updating feedback questionnaires. The registered manager should consider including a photograph of each resident with the medication and administration record. The registered manager should consider recording the individual wishes of residents in respect of dying and death and to make this available in the care plan. The registered manager should consider implementing a log record book to record all complaints and concerns. The registered manager should consider completing a schedule for recording all the dates of staff supervision. Primrose House DS0000013751.V251940.R01.S.doc Version 5.0 Page 23 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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