Inspection on 12/12/06 for Primrose House (Morecambe) Ltd

This inspection was carried out on 12th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Primrose House (Morecambe) Ltd 19/01/06

Primrose House (Morecambe) Ltd 26/07/05

Primrose House (Morecambe) Ltd 08/03/05

Primrose House (Morecambe) Ltd 01/06/04

Primrose House (Morecambe) Ltd 10/03/04

Primrose House (Morecambe) Ltd 28/10/02

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Primrose House (Morecambe) Ltd Primrose House Middleton Road Middleton Morecambe Lancashire LA3 3JJ Lead Inspector Mrs Joy Howson-Booth Unannounced Inspection 12 December 2006 1.30 th Primrose House (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 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 (Morecambe) Ltd DS0000009716.V300931.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 Adults 18-65. 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 (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Primrose House (Morecambe) Ltd Address 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 Middleton Road Middleton Morecambe Lancashire LA3 3JJ 01524 853385 Primrose House (Morecambe Limited) Mr Anthony David Grundy Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Primrose House (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 Brief Description of the Service: Primrose House (Morecambe) Limited is a home for up to 6 people with severe learning and physical disabilities, the present (purpose-built) building opened in 1998 but the Primrose House service has been in operation since 1988. The service was established as a charitable organisation by one of the parents of a current service user who found that there was no satisfactory service provision existing locally to meet complex needs. A Board of Trustees appointed a Registered Manager to undertake the day-to-day management of the home. A responsible person has also been appointed to monitor the service. The Board of Trustees meets on a regular basis to review the service and plan future developments. The ethos of the home is to provide quality services to people who have a profound learning and physical disability and it believes that opportunities should be provided to enable the people supported to live independent lives within the confines of their disability. The current fees are £1025.26 per week. Primrose House (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first site visit and was unannounced so the registered manager, staff and service users were not aware of the visit. The site visit forms part of the overall inspection for the home which makes sure people are being cared for properly and to make sure the home is a safe place for people to live in. As well as the site visit, judgements have been made about the service based on information supplied by the registered manager. Comment cards were also sent out to service users’ relatives, GPs and healthcare professionals. The site visit took place over one half day and an additional short visit and included taking time to sit and speak with one resident, observing staff on duty performing the day-to-day routines, speaking with staff, examining documents held in the home and speaking with the registered manager. The inspector looked around the home, including communal rooms, bathrooms and toilets. The tour also provided an opportunity to find out about any improvements made and to see if the home was a comfortable, clean and safe for people to live in. Additional information was also supplied from a pre-inspection questionnaire completed by the registered manager. The site visit was positive with everyone welcoming, friendly and co-operative during the visit. Primrose House has been assessed as an excellent. One requirement has been made which was being addressed at the second visit. A small number of recommendations have been made. What the service does well: The home continues to provide an individualised and person-centred way of giving care to the service users who live at this home. The home was built especially to meet the needs of people who have both physical and learning difficulties and is furnished to a very good standard which provides a homely and relaxing environment. The six service users have all been at the home for a number of years and have built up relationships with each other and members of staff. Each service users has their own personalised room which they can use freely, along with communal areas. Each resident has their own timetable for care and activities which uses the information provided by relatives and from experience to plan and provide an excellent quality of life. Primrose House (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 6 Staff spoken with are experienced and trained and are given support from each other and members of the management team to ensure a high quality of care is always given. Training continues to be provided to staff, including specialist training. Staff are properly employed with all the necessary checks being taken to ensure service users are safeguarded. Positive comments have been received from relatives and three healthcare professionals which included “”staff will also get in touch if there are issues relating to clients physical disabilities, and are always willing to take advice.” The registered manager of the home takes any concerns and issues seriously, with prompt and appropriate action being taken. One comment made by a relative was followed up by the inspector who found that the issue has been addressed by the home with a positive outcome. The home continues to be maintained to a high standard, with an ongoing redecoration programme in place. The home has achieved the Investors in People Award and the ISO 2001 award. Both these award mean that the home provides support and training to staff and also has the necessary paperwork and ways of work in place to ensure staff know how to provide good quality care. Information supplied by the home confirms that there are a range of policies and procedures which ensure service users are provided with the care they need and respects their rights irrespective of their race, gender, disability, sexuality, age, religion or beliefs. Staff spoken with confirmed that they are confident in the management of the home and the management team are always there for support and advice and, importantly, to listen to them. One comment made “there is never a time when I can’t go to David (David Grundy, registered manager) if I need help or advice”. Monthly staff meetings are held which gives staff an opportunity to discuss as a group any issues or concerns. What has improved since the last inspection? All service users now have their own individual person centred care plan which provides written information over how they make their needs known, their likes, dislikes, preferred routines and ongoing support and care needs so that staff are fully aware of how these need to be met. Healthcare records are now being more accurately maintained. The staffing in the home has now improved, with only a small number of staff having left since the last inspection. Staff spoken with felt that because there is a more consistent staff team they have been able to make sure service users Primrose House (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 7 did not miss their preferred community activities, like swimming and going to College. Risk assessments are now carried out on a monthly basis, particularly for the use of bed rails, etc. 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 (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Primrose House (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are very good arrangements in place to make sure information is gained and given so that all parties know identified needs will be met. EVIDENCE: There have been no new service users admitted to this home since the last inspection. The home has a comprehensive assessment which would be used, along with an expected care management assessment, to ensure the needs of any prospective service user were fully known prior to making a judgement about moving into the home. At a previous inspection, three service user files were examined and found to contain written Terms and Conditions (including a residency agreement) which outlines all the required information. This document has been signed by the respective family member as the service users lack the capacity to do this for themselves. Primrose House (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. There are clear and very comprehensive care documents in place which enable staff to fully know, understand and meet service users needs with dignity and respect. EVIDENCE: Person Centred Planning (PCP) care plans have now been implemented for all the service users in the home. PCP involves the service user (where possible), staff members, relatives and other professionals providing information so that an individualised care plan can be developed which is written from the individual person’s point of view and incorporates aspirations, needs and their preferred lifestyle. Evidence was seen that each service user has a review of their PCP, to which they, their parents, healthcare and other professionals are invited. Primrose House (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 11 At this inspection, three files were examined and found to be well laid out and providing accessible information for the staff team. The PCP’s have been written with statements like “I want to feel that I am in control” and “I want to have my choices respected even if people disagree with the choices I make” and “I want to be able to make decisions that affect my life”. This means that the reader can be provided with a viewpoint that is from the service user themselves. PCP also include passports to communication. These detail a range of information and pictures which give staff at the home and a separate passport for use by people in the wider community (for example Tutors at the College). These passports were examined at the previous inspection and were seen to give information over the specific ways that the individual service users communicate their wishes. For one service user this may only be by lifting up one arm or by moving their lips together but are all important and subtle communication methods that may be missed by those not aware. As well as these, service users also have “objects of reference” – for example, an apron which provides a tactile symbol that she is to be taken for something to eat. Another lady has a handbag which signifies that she is going out. The PCP care files evidenced that risk assessment updates are carried out on a monthly basis for areas of risk, for example, the use of bed rails. Discussions with staff confirmed that the PCP care files work well. One comment was made that the care files are “brilliant”. Information gained verbally from staff evidenced that there is a very thorough and extensive knowledge of the individual service users, particularly by the key workers concerned. It is clear that the attitudes of staff towards the care they need to provide is not just at a functional level but is also seen as a way of providing a quality of life and interaction with the service users concerned. Comment cards received from relatives indicate that they are kept informed of important matters and are consulted about their care. Primrose House (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Service users are supported to have an excellent quality of life. rights are respected at all times. EVIDENCE: From the care files examined it was clearly evidenced that the staff continue to enable the service users to have very good quality and individual lifestyle. Central to the home’s aims and objectives is the promotion of the individual’s right to live an ordinary and meaningful life, both in the home and in the community appropriate to their peer group. Due to the abilities of the service users, employment is not something that can be considered at present. However, most of the service users attend the local College accessing a range of different courses. Information regarding community and other activities are reliant on this being obtained by staff. Primrose House (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 13 Service users From discussions with staff and from examining care records, a number of community activities are enjoyed, including swimming, meals out, music club, local Colleges, SPACE (sensory centre), attend football matches and dance class. All activities are planned based on the individual service user’s own likes and dislikes, although some are tried to provide an opportunity for development through experience. These activities are recorded on an Individual Plan Review Matrix which outlines the day-to-day activities and routines for each individual service user and are “ticked” when specific activities or events take place. These are maintained by staff and a parent who confirmed that attendance at activities has much improved. It was noted that some sections have not been ticked but staff spoken with confirmed that the activities have taken place but they have not remembered to tick the appropriate box. Discussions with staff confirmed that there is a much more stable staff team which has meant activities have been attended much more regularly. The PCP care plans also provide information over dedicated morning, mealtime and evening routines which are written in the first person. One care plan has been signed by the service user it relates to. Discussions with one service user confirmed that he continues to be happy with his current lifestyle and the support he receives from the staff. Other service users were unable to comment on their lifestyles but were enjoying a range of activities (both inside and outside the home) during this inspection visit. Discussions with the staff team confirm that good working relationships are maintained and, from this and other inspection visits, it is again noted that there are positive interactions with service users. Family and other contacts are maintained. Service users have free access to all the communal areas in the home, which are accessible as needed. Discussions with the cook during this inspection noted that there have been no changes to the provision of meals. Meals provided within the home appear to be appropriate to the service users and are on an individual basis, including a range of food and drinks being supplied during the day – breakfast, brunch, lunch, tea, supper or as and when the service user indicates they wish to have something to eat or drink. Any cultural/religious/medical dietary needs would be ascertained at the point of referral/assessment. Guidelines on how to support each individual service user at mealtimes (positioning, utensils, individual indications, etc), along with likes and dislikes for food are in the service users own PCP care files. Primrose House (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Personal and healthcare support is provided by a dedicated and experienced team, with specialist advice and guidance being incorporated. EVIDENCE: Discussions with staff again confirmed that personal support is provided in a sensitive and dignified way, with privacy always being paramount. There was a very good understanding of the communication methods of each service user and an awareness to maintain as much independence as possible. Staff spoke about the care they provide in a positive way and were fully aware of the differing health needs of individual service users. Healthcare records were seen to be accurately maintained and evidence that a range of healthcare professionals are involved. Comment cards from three healthcare professionals confirmed that the home communicates and works in partnership with them; there is always a senior member of staff to speak with; they are able to see the service users in private and specialist advice is always incorporated into the care plan. One comment card stated “staff will also get Primrose House (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 15 in touch if there are issues relating to clients’ disabilities and are always willing to take advice.” Medication records were examined, along with a sample of nomad cassettes for service users. Records were accurately maintained. The following advice was given : When medication administration times are changed, whilst these have been discussed with the service user’s GP the (medication administration sheet (MAR) still records the original timings. This should be discussed with the chemist so that medication timings reflect the agreed time for administration. There are no controlled drugs in the home, although there is a procedure in place should this be necessary. Primrose House (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Service users are listened to and safeguarded by staff at the home EVIDENCE: As noted in the previous inspection report, the home has a complaints procedure which is accessible to relatives and visitors. Service users at the home would not be able to use this procedure but have relatives and staff who clearly act as advocates on their behalf. The registered manager confirmed there have been no changes to this procedure. Information supplied by the home indicated that one complaint had been made since the last inspection. This was discussed with the registered manager who confirmed he had recorded it as a complaint although it was a concern raised by a relative. The commission was already aware of this and was satisfied that the registered manager had taken appropriate and prompt action to address the issue raised. Comment cards received from three relatives indicate that they have not had to make any complaints but are aware of the home’s complaints procedure. Comment cards received from three healthcare professionals indicate that they have not received any complaints about the home. Resident’s Person Centre Plan (PCP) files contain information which is linked to their individual likes and wishes including – “what’s important to and for me” Primrose House (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 17 and “things you should know about me”. This also includes the specific ways the different service users use to communicate feelings. This enables staff to listen and act on the responses provided by those service users who are unable to verbalise their views. Only one resident in the home is able to be actively involved in the home’s meetings and it was confirmed that he still enjoys contributing to these. It was confirmed that safeguarding adults training continues to be covered in both the home’s induction training programme, in the formal LDAF (Learning Disabilities Award Framework) training and in National Vocational Qualification training. The registered manager has also made available to staff a copy of the conclusion and recommendations of the report in the Joint Investigation into the Provision of Services for people with Learning Disabilities in Cornwall – the Cornwall. From discussions with staff, reading this report has heightened their awareness in this area and has given the staff team an opportunity to discuss an important issue in the care of vulnerable people. Staff confirmed that the home’s policy on Whistle-blowing has been given to them. There is an abuse procedure in place in the home which complies with the Department of Health’s document “No Secrets” and discussions with staff during this inspection visit confirmed they have access to this and also know the procedure to follow should they have any concerns. Discussions with staff confirmed that the home has an open culture where issues can be raised and discussed with action taken as appropriate. One member of staff said that “there is never a time when I can’t go to him (David Grundy, registered manager) if I need help”. The registered manager has previously confirmed that staff are trained in breakaway techniques but only staff who have undertaken this training are able to work unsupervised with service users. Newer staff also confirmed that they are never left alone with a service user until both they and the registered manager are confident in their ability to deal with behaviours that challenge. Key workers manage the personal finances for their key service users – these being audited on a monthly basis by either the registered manager or the deputy manager. Staff do not get involved in other financial affairs relating to the service users – these are generally undertaken by their own relatives. Primrose House (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Primrose House is a safe and well-maintained place for people to live in. EVIDENCE: A tour of the home found that it continues to be homely and comfortable which is kept clean and tidy with no offensive odours. The home has a modern layout over one floor with excellent furnishing and fittings provided in a cheerful and airy environment. All communal areas are accessible to the service users, but most need staff support to do this. Information supplied by the home indicated that the service users continue to enjoy activities in the landscaped gardens which included barbeques during the summer months and time in the sensory area. Primrose House (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 19 There is a planned maintenance programme in place with monthly checks being carried out by the registered manager. The home has all the appropriate aids and adaptations in place to ensure service users are afforded dignity and respect whilst being provided with personal care. All service users rooms have locks on their doors to afford privacy. Each room is decorated and furnished in a manner that reflects the service users own preferences, colour schemes and interests. There are no CCTV cameras in use in the home. There is a separate laundry at one end of the building which the registered manager has already confirmed adheres to the health and safety requirements. Information supplied by the registered manager confirmed that the home has a policy and procedure for the control of infection which was last reviewed in 2001. It is advised that this policy and procedure be reviewed to ensure it reflects current good practices in the control of infection. Staff spoken with did not confirm that they have had training in infection control. This is something the registered manager needs to address. Primrose House (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Service users are cared for by a professional, supportive, trained and very committed team of staff. The homes recruitment procedures are thorough and ensure the vulnerable service users are safeguarded EVIDENCE: Concerns raised at the last inspection over retention of staff have been addressed as there is a new management structure in place which has resulted in extra staff being employed. Discussions with staff during this site visit confirmed that staffing levels are maintained to a good level. Staff appointed since the last inspection confirmed that the registered manager followed the home’s recruitment procedure. Induction was also provided as an extension to the recruitment process with both members of staff being rotered alongside experienced staff. Both staff confirmed they were never expected or asked to work alone until both they and the registered manager was confident in their abilities. Comment was made that “it’s very good here” and “help is always available”. Primrose House (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 21 These staff also welcomed and enjoyed their induction and are looking forward to starting the Learning Disability Award Framework (LDAF) and National Vocational Qualification (NVQ) training. Staff records were seen and found to contain all the required information. The home has a thorough recruitment procedure in place which is adhered to for any recruitment of staff. Advice was given that the registered manager should obtain a copy or see original certificates for any external training certificates said to be held by new members of staff. A number of staff have worked at the home for sometime, some with previous experience of care and five being qualified nurses. There is an ongoing training programme for staff which includes LDAF training and National Vocational Qualification Training to both Level II and Level III. Information supplied by the home confirmed that there are currently 62 of staff trained to NVQ Level II, with one member of staff completed NVQ Level III and another about to commence this training. Four members of staff are to commence NVQ Level II in January 2007. Other training undertaken by staff includes : breakaway training (provided by a specialist Physical Intervention Co-ordinator for the Cumbria PCT); person centred teams; sexuality; autism awareness and a number have completed the safe handling of medicines course. One member of staff is to commence a course in sign language in 2007. As well as this mandatory training is also provided. There may be the need to look at training in infection control and food hygiene for the future. Training records were seen for staff during the site visit. Staff confirmed that formal supervision is provided every 3 months. Staff appraisals are also held on a yearly basis. Supervision records were seen during this site visit which evidenced that staff are given supervision on a regular basis and given opportunity to review their care practices and highlight future training needs. Primrose House (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The home is well managed by an experienced and competent manager EVIDENCE: The registered manager has achieved a range of qualifications, including the Registered Managers Award. Ongoing training was evidenced as courses have been attended in “Equality and Diversity, “Person Centred Thinking”, “Coach to Person Thinking”, “Aggression Management Update” and “Fire Lecture”. The recent management structure changes appear to be working well and there is a good working relationship between the Board of Trustees, the responsible individual, registered manager and the deputy manager. The registered manager confirmed that the existing quality assurance systems remain place and include the ISO 2000 (obtained in December 2001) and the Primrose House (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 23 Investors in People Award (obtained in June 2003). These awards are based on the input and support provided to staff through policies, procedures and the investment in training provided. Staff confirmed that staff meetings are held every month and minutes provided for those who were unable to attend. As well as this, there are monthly visits by the responsible person from the Board of Trustees who submits a report to the commission. The registered manager was advised these can now be kept in a file for inspection at future site visits. It is a main part of the home’s ethos that the service users underpin the activities that take place in the home. The home has 6 monthly review meetings when all involved parties (relatives, health professionals, key workers, etc.) are invited to contribute to the person centre approach to care which is used in the home. The registered manager has previously confirmed that himself and members of the Board of Trustees meet on a monthly basis to look at ongoing work and to make developmental plans for the whole areas within the home. In addition, relatives and other professionals are invited to complete a “Quality Feedback Questionnaire” at the time of any reviews and regular reviews of systems, policies and procedures take place to maintain the homes ISO 2000 status. Regarding health and safety within the home, the registered manager works hard at ensuring all staff receive the appropriate mandatory training. Information supplied by the registered manager confirmed that all the required checks are carried out on equipment and facilities within the home. During the site visit a number of certificates were sampled, including the hard wiring certificate for the home, the portable applicance test certificate, the gas certificate and various certificates for the maintenace of hoists within the home. The registered manager confirmed that the home has a fire risk assessment in place and further advice is to be requested from the fire safety officer. The accident records were also seen and appear to be kept appropriately with any necessary action being taken if needed. Advice was given that all policies and procedures should be reviewed on an annual basis and the registered manager confirmed he was currently reviewing all the home’s policies and procedures to ensure they reflect current legislation and good practices. Risk assessment were seen on individual service users files. Primrose House (Morecambe) Ltd DS0000009716.V300931.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 Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 x 4 x 3 X X 3 x Primrose House (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 25 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 YA42 Regulation Requirement Timescale for action 19/12/06 23(4)(c)(i) The Care Homes Regulations 2001 require the registered person to make adequate arrangements for detecting, containing and extinguishing fires. During this inspection fire doors were seen to be kept open with wedges as the automatic door release mechanisms were not working. The registered person must provide the commission with an action plan for the repair/replacement of the door mechanisms within 7 days and with immediate effect to ensure fire doors are not wedged open. 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 YA24 Good Practice Recommendations To continue with the ongoing maintenance programme for the home DS0000009716.V300931.R01.S.doc Version 5.2 Page 26 Primrose House (Morecambe) Ltd 2. 3. 4. YA13 YA20 YA34 5. 6. YA42 YA30 The individual plan matrix records should record when individual activities are done Medication records sheets should record the actual timing medication is given When potential staff indicate they hold or have had training the registered manager should see their original certificates and record this in their file or should take a copy of the certificate to be held on file. The home’s policies and procedure should be reviewed at least annually or when needed to ensure they reflect current legislation and current good practices Staff should have training in infection control and food hygiene Primrose House (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 (Morecambe) Ltd DS0000009716.V300931.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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