Inspection on 27/09/07 for Primrose House

This inspection was carried out on 27th September 2007.

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 House 01/09/06

Primrose House 19/05/06

Primrose House 26/09/05

Primrose House 07/07/05

Primrose House 05/10/04

Primrose House 29/06/04

Similar services:

Springfield House

The Shelley

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Primrose House Primrose House Perry Hill Worplesdon Guildford Surrey GU3 3RF Lead Inspector Amanda Longman Unannounced Inspection 27th September 2007 11:00 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.V345465.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.V345465.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.V345465.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 31st October 2006 Date of last inspection Brief Description of the Service: Primrose House is a large house in Worplesden 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 home operates a person-centred approach to care to ensure individual diversity needs are addressed. The weekly charges range from £400-£550. Extra charges only relate to direct expenditure such as hairdressing, newspapers and personal toiletries. Primrose House DS0000013751.V345465.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of the service was an unannounced ‘Key Inspection’. It was a thorough look at how well the service is doing. It took in to account detailed information received from the provider about the services and care provided at Primrose House and the people who live there. Seven surveys were received from residents or their relatives, giving their views on Primrose House. The inspector visited Primrose House on 27 September 2007 and spent approximately seven hours at the home. During this site visit the inspector toured the home, observed care practices. spoke with service users and staff and examined care records. The manager was on leave and not present at the visit. What the service does well: What has improved since the last inspection? A large amount of refurbishment has recently been undertaken, including new chairs and tables. A previous recommendation to provide radiator covers has been implemented. Primrose House DS0000013751.V345465.R01.S.doc Version 5.2 Page 6 Medication procedure has been improved in line with the requirement made at the previous inspection. The number of staff qualified to, or working towards NVQ level 2 has increased. 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. The summary of this inspection report can be made available in other formats on request. Primrose House DS0000013751.V345465.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Primrose House DS0000013751.V345465.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. The home is able to demonstrate that service users needs are thoroughly assessed prior to admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information received from the manager prior to the site visit stated, “We assess all prospective residents, either in their own environment and/or when they come for the trial day. We gain detailed information on their health and social care needs to ensure that we are able to provide them with the correct level of support and that we can meet all their needs. We liaise with all concerned, particularly health professionals and significant people involved in their care so that we have as much information as possible prior to and during the admission process. We also try and discuss any concerns that the resident might have regarding admission and ensure that these are dealt with sensitively and appropriately. “ On the day of the site visit three service users files were reviewed and all Primrose House DS0000013751.V345465.R01.S.doc Version 5.2 Page 9 contained detailed assessment information which included their health and care needs, what they wished to be called, their likes and dislikes, their preferred routine and their life history. One file was missing the detail on life history. This was raised with the person in charge who will follow this up. Primrose House DS0000013751.V345465.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. Service users have appropriate care plans and their healthcare needs are met. Service users’ individuality, dignity and privacy are respected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information received from the provider before the site visit stated “We treat people as individuals and promote a person-centred approach to care planning. Being a small home the management has daily contact with all the residents and regular contact with their relatives. We also have planned reviews with the relatives every six months and more frequently if necessary, and the care plans are reviewed at least monthly and more frequently when necessary.” Three care plans were reviewed on the day of the site visit. All were detailed including capabilities, needs and preferences, cultural or religious needs and aspects of care and they stressed dignity and promoting choice and independence. Care pans contain monthly comments on progress made and were all reviewed on a six monthly basis. Primrose House DS0000013751.V345465.R01.S.doc Version 5.2 Page 11 Care plans detail service users healthcare needs and it could be seen that where issues had arisen a paper audit trail, through the communications book and the diary, provided evidence of appropriate referrals being made to health care professionals and followed up. An individual list of medical appointments was not maintained on each service users file but the deputy manager will follow this up. The home has a brief Medication policy with detailed procedures being held in the medication cupboard. Medication was stored appropriately. The home does not use any “homely” remedies and all medication was individually prescribed. Staff have received training in the administration of medication. Medication records were examined for the three service users whose care plans were examined. All were up to date. The individual record sheets contain photographs of the service user as a check that medication is administered to the correct individual. The inspector recommended that an up to date summary of each individual’s current medication be maintained on their care plan file. The home has a detailed policy on privacy and dignity and it was very obvious on the day of the site visit that everyone living in the home was respected as an individual and treated with dignity. Staff displayed an easy and kind manner and chatted readily with service users, all of whom spoke highly of the staff and the care received. The home had a happy and relaxed atmosphere. Comments received from relatives included “She is looked after so well it has taken years off her”, “I couldn’t wish for my mother to be a more caring and loving environment” and “Individual needs are always paramount”. Primrose House DS0000013751.V345465.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. Service users enjoy the lifestyle provided at Primrose House. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information received from the manager prior to the site visit stated “We have planned activities at least twice daily as well as activities gearing towards their individual needs, such as shopping and trips to the pub. This ensures that residents can continue with their interests and hobbies and participate in the wider community. The activity schedule encourages family involvement as well as involvement in community events, and visits from outside organisations, such as church services, Pets as Therapy and theatre groups.” Comments from relatives included: “The programm of activities is stimulating and enjoyable”, “visitors are always welcomed”, “The staff are always welcoming and caring” and “activities throughout the week to stimulate.” The home has a very social atmosphere. All but one of the current service users choose to spend their day socially engaged in the lounges or conservatory. However, personal choice is encouraged and if service users prefer to pass time quietly in their room they are supported to do this. Evidence for this was through discussion with staff and service users. There Primrose House DS0000013751.V345465.R01.S.doc Version 5.2 Page 13 was also evidence of choice about daily routines. Care plans detailed individuals’ preferences, for example times of getting up or going to bed and the name by which they preferred to be addressed. One service user prefers to have their diner in the evening rather than at lunchtime and this is catered for and one service user who smokes is enabled to do so safely and legally. Service users may have a key for their room but currently no one wishes to hold one. Evidence gathered on the day of the site visit confirmed that the home offers a variety of stimulating activities and although there is a weekly schedule of morning and afternoon activities these will vary from the time table depending on what service users want to do and other circumstances such as the weather. For those service users who either choose not to join in group activities or are not able to, staff engage in one to one activities such as looking through photos or discussing news topics. Service users are supported to go out, two had been assisted to go to the local pub the day before the site visit. Activities observed on the day of the site visit included dominoes and a beetle drive. Approximately half the service users joined in these activities which were facilitated by an activities organiser who was supernumery to the staff compliment for the day. Activities are discussed at residents meetings and evidence showed that service users would like to go out more. To this effect the homes development plan includes the purchase a means of transport in January 2008. Relatives and friends are welcomed in to the home at any time. This was evident talking to service users and staff and from the comments received on relatives’ surveys. Care plans include individuals’ religious or cultural needs. Currently the home offers a multi faith religious service with which service users are happy. Staff spoken with demonstrated an understanding of individuals’ needs and the deputy manager stated that should there be a lack of understanding of how best to meet an individual’s religious or cultural needs they would consult the family or other appropriate experts. Service users spoke highly of the food served by the home. Lunch is freshly cooked each day and a choice is offered. A cooked supper is also offered such as cauliflower cheese, macaroni cheese or sausage rolls. Sandwiches and salads are also offered as alternatives. Snacks and drinks are provided throughout the day. The cook has recently been appointed and is part time cook and part time care assistant. She is currently being trained and has yet to attend a food hygiene course. As the home caters for some people with dementia the cook should also attend nutrition courses relating to the care of people with dementia. The deputy manager was knowledgeable in this area and weight is monitored where there are concerns. Most service users eat in the dining room that was brightly and pleasantly furnished. On the day of the Primrose House DS0000013751.V345465.R01.S.doc Version 5.2 Page 14 site visit new, circular dining tables were being delivered to aid social interaction. A small number of service users require assistance with eating and staff were generally observed to be caring and helpful in their approach. However the inspector did observe a care worker who was standing up whilst assisting one service user rather than sitting themselves at the same level of the service user. This was raised with the deputy manager who undertook to talk with the care worker. Primrose House DS0000013751.V345465.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. Service users, their friends and relatives are happy that their complaints are appropriately dealt with and service users are safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided by the manager before the site visit stated “On induction our staff are trained in the Safeguarding of Vulnerable Adults, and this is continuous. The safety and welfare of our residents is paramount and this ethos is promoted by the management. We have an open environment and encourage discussion and suggestions, from staff, visitors and most importantly the residents. We also have a whistleblowing policy in place, as well as a complaints policy and procedure which are reviewed regularly. Residents meetings are held frequenlty where open and honest discussion is encouraged and the residents are encouraged to express their views on the running of the home. The responses from our quality assurance, residents and relatives meetings are always followed through and feedback given to all concerned. The residents have the opportunity to express themselves in a number of ways and staff are trained to spot signs of abuse in vulnerable residents and know Primrose House DS0000013751.V345465.R01.S.doc Version 5.2 Page 16 how to act if they suspect abuse. Relatives are actively encouraged to express their views and share concerns, even minor, with management or staff. The adult abuse procedures and whistle blowing procedures were found to be appropriate at the last inspection. Unfortunately the procedures were not available to view at the site visit but the inspector had no reason to doubt that they remained consistent with those required. Staff spoken with were familiar with appropriate procedures and training in safeguarding vulnerable adults had been provided. The Commission has not received any notification of concerns regarding vulnerable adults nor have we received any notification of complaints. The complaints procedure was available in the Service User Guides provided in every bedroom in the home. Relatives’ comments were very positive and service users spoken with said they would raise any concerns with the management or staff. Primrose House DS0000013751.V345465.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. Service users enjoy the environment provided at Primrose House. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In the information provided by the manager prior to the site visit it was confirmed that all required gas, electrical and safety tests had been undertaken. Unfortunately no dates were provided for these checks and the manager was not present on the day of the site visit to confirm dates. However, the inspector undertook a tour of the building, spoke with staff and service users and examined those maintenance records that were available. The environment was seen to be safe and well maintained. A large amount of refurbishment has recently been undertaken and more is planned in the development plan, over the next few months. The two lounges and the conservatory are bright, homely and very comfortable, with new chairs having recently been provided. On the day of the site visit new dining tables were being delivered. Staff and service users spoke highly of the upgrades currently Primrose House DS0000013751.V345465.R01.S.doc Version 5.2 Page 18 being undertaken. The pre-inspection information received also confirmed that health and safety audits were undertaken. Comments from relatives stated: “…improvements to the building …done with great consideration for the residents, I cannot praise the staff enough”.. The Home is “clean and welcoming”. During the tour of the home the inspector did notice two bedrooms had an odour of urine. The senior member of staff on duty at the time commented that they were aware of the problem and were planning to shampoo the carpets and talk to the service users and their relatives about how to manage this and possibly change the flooring. The communal areas of the home were all bright and homely, clean, pleasant and hygienic. Appropriate bathroom and toilet facilities were seen to be available, with appropriate assistance equipment. One annex of the home has two upstairs rooms that are not accessible by lift. Those residents currently occupying these rooms are able to negotiate the stairs with assistance but consideration may need to be given in the future as to a suitable method of safely accessing these two rooms. Moreover, these two rooms were cold on the day of the site visit. This was not an issue as the service users, by their choice, were spending the day down stairs in the communal facilities. The senior member of staff showing the inspector round commented these rooms were cold and stated she would ensure the heating was turned up in them during the day, in case the service users wished to spend time in them in the day. Primrose House DS0000013751.V345465.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. Service users benefit from caring and competent staff, however the staffing policy needs to be reviewed and a new training plan needs to be devised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided before the site visit stated: “The home always has more than sufficient staff on duty and in the bank, and the duty rotas are completed in advance so that leave and absences can be covered within the team without the need for agency staff.” The staffing policy stated that four staff would be on duty from 8.00am until 2.00pm; one from 8.00am until 9.00pm; three from 2.00pm until 8.00pm and two from 8.00pm until 8.00am. On the day of the site visit there was one member of staff on from 7.00am until 4.00pm; one from 8.00am until 2.00pm; one from 8.00am until 8.00pm; one from 2.00pm until 8.00pm and one from 8.00pm until 8.00am. This was not inline with the staffing policy. It was approximately one worker fewer on each shift. This could not be discussed with the manager on the day of the site visit as they were on holiday at the time of the site visit. but one would expect the manager to be supernumery anyway for the majority of the time. The staffing policy states two workers are on duty throughout the night. However, the inspector learnt on the day of the site visit, this is normally only Primrose House DS0000013751.V345465.R01.S.doc Version 5.2 Page 20 one care worker, backed up by a second care worker who lives on site and can be called if necessary. However at the time of the site visit the second care worker was on holiday, which meant the lone care worker at night would have to call another care worker, not on site, if assistance was needed. This calls into question how effective the night time cover is; for example should someone require two care workers to assist them, or should someone’s care plan state they wished to be assisted by a female care worker and the only care worker on was a male care worker. This also calls in to question safety issues – should the one care worker be assisting someone when another service user calls. This was discussed with the deputy manager on the day of the site visit who was confident another locally base care worker could be present quickly after being telephoned, and evidence from service users and relatives was that they were satisified with the level of support. Even so, the home should review its staffing policy against the risk assessments for current service users and provide more adequate back up during night times at the home, to ensure the safety and choice of individuals is maintained. A previous requirement was made on the home to recruit a cook so that care staff were not distracted from their care duties by having to cook. A new cook has been recruited but this member of staff is still counted within the care staff establishment. On the day of the site visit, this did not distract from the care provided and comments from service users and their relatives were positive. These included; “Staff are extremely kind” and “staff try hard to look at her personal needs”. However, as stated above the staffing policy and the way in which cover is provided needs to be reviewed. Recruitment records for two employees were checked. All were in order apart from one employee only had one reference instead of two. Evidence was seen that staff supervision and staff meetings happen on a regular basis. NVQ training has increased and all staff except one are either qualified to NVQ level 2 or above or are working towards it. Evidence of training was seen but a training plan was only in place up May 2007. Primrose House DS0000013751.V345465.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. Service users benefit from a well run home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is run by a manager who is registered with The Commission and who is qualified and competent. Information from the quality audit received prior to the site visit stated: “We continuously achieve positive and highly rated feedback from our quality assurance questionnaires and regular contact with residents, their relatives and fellow professionals.” This was supported by the feedback from relatives questionnaires received before the site visit; all of which were 100 positive about the care home and the care received by their relatives. During conversations with service users on the day of the site visit, service users spoke of the high quality of care they received and this was borne out by the inspector’s observations on the day of the site visit. Primrose House DS0000013751.V345465.R01.S.doc Version 5.2 Page 22 The home has quality assurance tecniques in place, including audits of policy documents, procedures and health and safety mechanisms. Unfortunately no dates were submitted for policy reviews in the information provided before the site visit and these could not be confirmed on the day of the site visit as the manager was on leave. It was recommended after the previous inspection that policy documents be dated when reviewed and this is again strongly recommended. Evidence of a development plan was provided before the site visit and the newly refurbished lounge, and the new dining tables (cicular to encourage social interaction) being delivered on the dat of the site visit showed the development plan is being followed. The quality assurance procedures include regular service user meetings and evidence of these being held monthly in the three months preceeding the site visit were seen. (Evidence of requests from these being planned for is contained in the section above on activities and daily life.) Relatives comments relating to the quality of the management of the home included: “Primrose House is run by a team of staff who are expert in the field and extremely caring” and “I cannot praise Mr and Mrs Beeharry and their staff highly enough”, “a real home from home”. Service users financial interests are safeguarded. The home holds small amounts of money on behalf of service users, for example to pay for the hairdresser, newspapers or personal toiletries. Records are kept in an account book. Relatives sign to say what money they have given and staff write down any expenditure, and sign. The book is checked regularly by the manager and records can be viewed by relatives on demand. The home has an appropriate health and safety policy in place and provides induction training. The most recent Food Hygiene Report by Guildford Council Environmental Services confirmed that training was in place and gave the home 3 out of 5 stars and a rating of good. However, the recently appointed cook needs to attend food hygiene training. A previous recommendation to provide radiator covers has been implemented. The premises are secure and appear to be well maintained. Primrose House DS0000013751.V345465.R01.S.doc Version 5.2 Page 23 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 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Primrose House DS0000013751.V345465.R01.S.doc Version 5.2 Page 24 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 2 Standard OP15 OP27 Regulation 18 (1) © (i) 18 (1) (a) Requirement The new cook needs to receive appropriate training. The number and skill mix of staff on duty must ensure the needs of service users can be met. Two written references must be obtained for each employee. Timescale for action 27/11/07 27/12/07 3 OP29 19 (1) (b) Schedule 2, paragraph 5 27/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP8 OP9 Good Practice Recommendations It is recommended that an individual list of medical appointments be maintained on each service user’s file. It is recommended that an up to date summary of each individual’s current medication be maintained on their care plan file. DS0000013751.V345465.R01.S.doc Version 5.2 Page 25 Primrose House 3 3 OP15 OP27 4 OP33 It is recommended that the new cook attend a food hygiene course and a nutrition courses relating to the care of people with dementia. It is recommended that the staffing policy be reviewed and that it then be adhered to, to ensure the welfare of service users and that their safety, dignity and choices are maintained, particulary at night. It is recommended that policy documents be dated when reviewed. Primrose House DS0000013751.V345465.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 House DS0000013751.V345465.R01.S.doc Version 5.2 Page 27 - 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!