CARE HOMES FOR OLDER PEOPLE
Primrose House Perry Hill Worplesdon Guildford Surrey GU3 3RF Lead Inspector
Lisa Johnson Announced 07 July 2005 10:00 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 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 H58 S13751 Primrose House V228211 070705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Primrose House Address Perry Hill Worplesdon Guildford Surrey GU3 3RF 01483 232628 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Anne-Marie Antoinette Beeharry & Mr Ahmad Issac Beeharry 8 Muirfield Road, Woking, Surrey, GU21 3PW Mrs Anne-Marie Antoinette Beeharry Care Home (CRH) 16 Category(ies) of Old age, not falling within any other category registration, with number (OP) 16 of places Dementia - over 65 years of age (DE(E)) 4 Primrose House H58 S13751 Primrose House V228211 070705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1 Of the 16 (sixteen) accommodated 4 (four) may fall within the category of DE(E) 2 The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE Date of last inspection 05 October 2004 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 H58 S13751 Primrose House V228211 070705 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the first inspection carried out in 2005/2006. One inspector carried out the announced inspection over six hours. The main focus of the inspection was to review the requirements made at the last inspection. A tour of the premises took place and care plans, policies and procedures and other documents were sampled. The inspector spoke to six residents who live in the home and two visitors. The inspector also spoke to two members of staff. A number of comment cards were received from residents and relatives/ friends and these comments have been made reference to in this report. The inspector would like to thank the residents and relatives for their cooperation in carrying out this inspection. What the service does well: What has improved since the last inspection?
Primrose House H58 S13751 Primrose House V228211 070705 Stage 4.doc Version 1.30 Page 6 The home has compiled the information that is required for the homes statement of purpose. A quality assurance system is in process and a questionnaire has been implemented based on gaining feedback from residents. Staff files are now made available for inspection and were satisfactory. A light has been replaced in one bathroom and a portable heater has been removed from one bedroom. A care plan has been implemented for a new resident and risk assessments have been implemented in relation to possible aggression/ behaviours that challenge. What they could do better:
A cupboard was found unlocked which is kept for the storing of hazardous cleaning liquids. A requirement has been made that this cupboard must be locked at all times when not in use to protect the health and well being of residents. An electric shaver point was found broken in an upstairs bathroom and although this had been covered up to prevent access a requirement has been made that this is removed from the wall. There are some areas in the home such as the bathroom, corridors and dining room that need redecorating to ensure a homely and pleasant environment. The home must implement an action plan identifying times scales for completion of redecoration to the corridors and dining room and this must be made available to the Commission for Social Care Inspection. In one bedroom a sink edge was found to be in need of repair. A requirement has been made that a risk assessment is implemented to identify risks to the safety of residents while the internal decoration is taking place. Although the home has Protection of Vulnerable Adult procedures the home is required to obtain the updated copy of the local authority procedure. The homes complaint procedure is to be amended 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. Formal supervision for staff must be implemented so that all staff receive formal supervision at least six times in a year to ensure that all aspects of care practices and training and developments needs are identified. Primrose House H58 S13751 Primrose House V228211 070705 Stage 4.doc Version 1.30 Page 7 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 H58 S13751 Primrose House V228211 070705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Primrose House H58 S13751 Primrose House V228211 070705 Stage 4.doc Version 1.30 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 standard(s) 1, 2, 3, 4 & 5 The home provides adequate information to enable prospective residents decide whether they wish to live there. Contracts were in place. Assessments are completed prior to admission and trial visits are accommodated. EVIDENCE: The home has a Statement of Purpose, which clearly describes the services it is able to offer. A service user guide is made available to all residents. Care plans were sampled of new residents admitted to the home and there was evidence that assessments are completed prior to admission to the home. Each resident is provided with a contract of terms and conditions. Trial visits are accommodated in the form of visit or overnight stay. Primrose House H58 S13751 Primrose House V228211 070705 Stage 4.doc Version 1.30 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 standard(s) 7, 8 & 10 The health and personal care needs of residents were being met and set out in an individual plan of care. Residents were treated with dignity and respect. A policy has been implemented in respect of death of the resident and is handled with respect and as the individual would wish. EVIDENCE: Three care plans were sampled and were detailed in content. Plans were based on assessments and risk assessments have been implemented considering physical and emotional needs. All care plans are reviewed threemonthly and recorded. All residents are registered with the local G.P. Residents have access to chiropody, optician and the dentist and some home visits can be arranged. Specialist health care support is provided if required by the district nurse, occupational and physiotherapy and community mental health team. A policy has been implemented on privacy and dignity and staff were observed to be knocking on residents doors before entering and comments were received from relatives that they are able to visit in private. Comments were received from some health professionals who stated that the home communicates clearly and that they are able to see residents in private.
Primrose House H58 S13751 Primrose House V228211 070705 Stage 4.doc Version 1.30 Page 11 A policy is in place for ageing and dying based on respecting individual wishes and spiritual preferences are also supported. Primrose House H58 S13751 Primrose House V228211 070705 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14 &15 Residents were offered a range of recreational and social activities and were able to maintain contact with family and friends. Residents were offered a well balanced diet and choice of meals. EVIDENCE: There was an activities programme in place and at the time of the inspection a volunteer was attending, who carries out a weekly games session and the residents clearly looked forward to this and they were enjoying a game of dominoes. A music session takes place and there are occasional opportunities to go out for a drive, outings to the pub and two residents confirmed that that had been on a theatre trip. A volunteer with the P.A.T. dog scheme visits and birthdays are celebrated. The local vicar visits the home and a monthly service is held and a hairdresser visits the home. Residents are able to have visitors at any reasonable time. Comments received from relatives indicated that they were made to feel welcome and staff were courteous. Residents are given the opportunity to bring personal possessions with them into the home. Residents are able to make choices around meals and are offered the choice of having breakfast in their rooms if they so wish. A varied menu was in place and alternatives were available. The lunchtime meal was seen and was of a satisfactory standard and was nutritious. A majority of the residents spoken to were satisfied with activities and meals but there were some comments that there could be more variety in meals.
Primrose House H58 S13751 Primrose House V228211 070705 Stage 4.doc Version 1.30 Page 13 Although the home had implemented residents meetings these had not been updated for some time and a recommendation was made that the frequency of meetings is increased to maximise residents capacity to exercise choice and control. Primrose House H58 S13751 Primrose House V228211 070705 Stage 4.doc Version 1.30 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The home is able to demonstrate that there is an accessible complaint policy is in place and that residents and relatives will be listened to. Policies and procedures were in place to ensure that residents are protected from abuse. EVIDENCE: An adequate complaint procedure was in place and is accessible to all the residents. There have been no complaints received since the last inspection and comments received from residents and relatives indicated that they were aware of the complaints policy in the home. However a requirement has been made that the home amends the complaint procedure to state that the Commission of Social Care inspection can be contacted at any stage of a complaint if the complainant wishes to do so. Staff receive training in the protection of vulnerable adults and two staff members spoken to were aware of the policies in the home and were clear in their responses as to the appropriate action that would take if they ever witnessed an incident that would indicate any possible abuse. The local authority procedure for the Protection of Vulnerable Adults and whistle blowing policy was available. However the home is required to obtain the updated version of the local authority procedure. Primrose House H58 S13751 Primrose House V228211 070705 Stage 4.doc Version 1.30 Page 15 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 standard(s) 19, 20,21,23 & 24 The home is clean and hygienic. Resident’s live in comfortable bedrooms with their own possessions. 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: The home presents a homely atmosphere and was clean. There is a large lounge and a smaller lounge and a conservatory, which leads out from the lounge. These areas are comfortably furnished and decorated. A large kitchen is available and was clean and hygienic. There are ample bathrooms and toilets, which are accessible. Bedrooms were personalised to individual choices and some residents had bought in some of their own furniture and possessions and were decorated to a satisfactory standard. There is a pleasant garden at the back of the house, which is maintained, and at the time of the inspection a new wall was being erected to the front of the building.
Primrose House H58 S13751 Primrose House V228211 070705 Stage 4.doc Version 1.30 Page 16 There is some internal maintenance and redecoration that needs to take place. A sink edge in one resident’s bedroom requires repair. The upstairs bathroom was found to have a broken shaver point, which should be removed. The bathroom requires redecorating and maintenance work to take place around improving the bath tiles. Some paintwork is required to the dining room as some of the existing paintwork was peeling and some of the upstairs corridors need repainting. A requirement has been made that the manager supplies a copy of an action plan outlining the time scales for completing the redecoration work. The bathroom has been identified as the first priority. A further requirement has been made that a risk assessment is implemented in respect of the internal redecoration to protect the safety of residents. Primrose House H58 S13751 Primrose House V228211 070705 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 The staffing levels were adequate to meet the needs of the residents. Staff are supported to undertake training and development to ensure that they are competent to carry out their job. Appropriate recruitment procedures were in place to ensure the safety and protection of the residents. EVIDENCE: The staff duty rota was examined and levels were found to be adequate. The home also employs a cleaner and part-time cleaner. Staff training and development schedules were sampled and it was evident that mandatory training was taking place including fire safety, health and safety, infection control and medication updates. One member of staff was completing an induction programme. There are ten staff in post and four staff were completing National Vocational Qualifications in Levels two and three and one senior care worker was completing the level four qualification. The home has been in the process of recruiting new staff and two staff member’s personnel files were sampled and the required documents and police checks were in place. Primrose House H58 S13751 Primrose House V228211 070705 Stage 4.doc Version 1.30 Page 18 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36, & 38 The home is managed in an open and inclusive atmosphere. The home is implementing quality assurance system seeking views from residents. Adequate procedures are in place to safeguard resident’s finances. All staff should receive formal supervision at least six times a year. The registered manager must ensure that safe storage of hazardous substances is implemented to ensure the safety of residents. EVIDENCE: The manager holds a nursing qualification and is currently completing the Registered managers Award. The management approach of the home was found to be open and inclusive. Staff spoken to stated that they were well supported and that staff meetings take place. An equal opportunities policy was in place and the home has introduced a quality audit questionnaire based on feedback from residents. The staff look after small amounts of spending money on behalf of residents, although families are designated representatives
Primrose House H58 S13751 Primrose House V228211 070705 Stage 4.doc Version 1.30 Page 19 and act on their relatives behalf. Records were sampled and adequately maintained. The reason for expenditure is clearly recorded and receipts for purchases were maintained, for example hairdressing The manager has implemented a staff appraisal system and supervision is carried out informally. A requirement has been made that all staff receive formal supervision at least six times a year. A range of policies and procedures were available including health and safety. Fire records were sampled were found to be satisfactory. Food hygiene was being adhered to with temperature recordings in place. However the cupboard maintained for cleaning materials was unlocked and manager must ensure that the storage cupboards for maintaining hazardous substances are locked at all times when not in use. The downstairs toilet did not have hand towels and these were required to be replaced. Primrose House H58 S13751 Primrose House V228211 070705 Stage 4.doc Version 1.30 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 2 2 2 x 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 3 x 3 2 x 2 Primrose House H58 S13751 Primrose House V228211 070705 Stage 4.doc Version 1.30 Page 21 No 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 18 Regulation 13 ( 6 ) Requirement Timescale for action 1 month 7/8/05 1 month 7/8/05 2. 16 3. 4. 5. 6. 19 19 19 19 7. 19 8. 38 The home must obtain an updated copy of the local authority procedure for the Protection of Vulnerable Adults 22 (7) The complaints procedure must be amended to state that the Commission for Social Care Inspection can be contacted at any stageof a complaint. 23 (2) (c ) The broken shaver point in the upstairs bathroom must be removed. 23 (2) (b) The sink edge must be repaired in room 16. 23 ( 2) The upstairs bathroom must be (d) redecorated. 23 An action plan must be implemented identifying the time scales of the redecoration programme to the corridoors and dining room and must be made available to the Commission for Social Care Inspection. 13 (4) ( c) A risk assessment must be implemented to identify the all hazards that may be of detriment to residents when the redecoration work is being undertaken in the home. 16 (j) Hand towels must be provided in the downstairs toilet.
H58 S13751 Primrose House V228211 070705 Stage 4.doc 1 month 7/8/05 1 month 7/8/05 3 months 7/10/05 2 months 7/9/05 2 months 7/9/05 immediate 7/7/05
Page 22 Primrose House Version 1.30 9. 10. 36 38 18 (2) 13 (4)(c) All staff must recieve formal supervision at least 6 times a year. All cupboards maintained for storing hazardous substances must be kept locked at all times. 1 month 6/8/05 immediate 7/7/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 33 Good Practice Recommendations The home should consider increasing the regularity of residents meetings. Primrose House H58 S13751 Primrose House V228211 070705 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 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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