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Inspection on 13/10/05 for Primrose House Nursing Home

Also see our care home review for Primrose House Nursing Home for more information

This inspection was carried out on 13th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is welcoming. There is an emphasis on staff training; staff receive appropriate, and varied training. Staff training includes training in regard to meeting resident`s specialist and/or complex assessed needs Residents spoke positively of the care, and support received by the service.

What has improved since the last inspection?

Care plan information has been reviewed and information is more accessible due to the change in format. Improvements in the environment of the care home have taken place, which includes some new carpets and the development of a shower facility on the ground floor. Activities continue to be further developed. More staff are in the process of completing NVQ care courses, and there are plans for other staff to enrol on these courses.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Primrose House Nursing Home 765-767 Kenton Lane Harrow Weald Middx HA3 6AH Lead Inspector Judith Brindle Unannounced Inspection 13th October 2005 10:20 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 Nursing Home DS0000022936.V257029.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Primrose House Nursing Home DS0000022936.V257029.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Primrose House Nursing Home Address 765-767 Kenton Lane Harrow Weald Middx HA3 6AH 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) 020 8954 4442 020 8954 5376 hassam.cader@btinternet.com Mr Hassam Cader Mr Hassam Cader Care Home 23 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (23) of places Primrose House Nursing Home DS0000022936.V257029.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Minimum staffing notice applies Maximum of 23 elderly persons over the age of 65 in need of general nursing care Service users admitted to any of the four dementia care places must be offered a single room located on the ground or first floors only. 20th April 2005 Date of last inspection Brief Description of the Service: Primrose House Nursing Home provides nursing care for up to 23 elderly persons. The care home is registered to provide places for up to four service users needing dementia care. The home was first registered in September 1994. Mr H Cader, who is also the registered manager, owns the nursing home. Mrs Cader is a trained nurse, and works most days in the registered care home. The home is a large detached house close to Harrow Weald. The home has three floors, with lift access. There are 17 single rooms, and 3 shared rooms. There are bedrooms on each floor. The proprietor has agreed that service users with the diagnosis of dementia are offered single rooms on the ground, and first floor only. Four bedrooms have either an ensuite toilet or an ensuite toilet and bath. Communal rooms are located on the ground floor. The home has a large accessible enclosed garden. There is parking for several cars on the forecourt of the care home. Primrose House Nursing Home DS0000022936.V257029.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place throughout 4.5 hours during a day in October 2005. There were no vacancies at the time of the inspection. The inspection included a tour of the premises, inspection of a variety of records including care plans. The registered manager/provider Mr Cader was present for most of the inspection. Mrs Cader was on duty throughout the inspection. The inspector was pleased to speak with several residents, a relative of a service user, and a number of staff. Staff kindly made available all the documentation requested by the inspector. The inspection focussed on assessment of 15 National Minimum Standards for Older persons, and evaluation as to whether requirements, and recommendations from the previous inspection had been met. All the National Minimum Standards assessed during the unannounced inspection had been met or almost met. Information about the Commission for Social Care Inspection was supplied by the inspector to several residents. What the service does well: What has improved since the last inspection? Care plan information has been reviewed and information is more accessible due to the change in format. Improvements in the environment of the care home have taken place, which includes some new carpets and the development of a shower facility on the ground floor. Activities continue to be further developed. More staff are in the process of completing NVQ care courses, and there are plans for other staff to enrol on these courses. Primrose House Nursing Home DS0000022936.V257029.R01.S.doc Version 5.0 Page 6 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. Primrose House Nursing Home DS0000022936.V257029.R01.S.doc Version 5.0 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 Nursing Home DS0000022936.V257029.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1 (partially) and 3 Arrangements need to be in place to ensure that all residents, and others can access documentation that they need to gain knowledge about the service provided, and to enable them make an informed choice about where to live. Arrangements are in place to ensure that prospective residents receive a comprehensive assessment of their needs. EVIDENCE: An amended service user guide about the service was supplied to the Commission for Social Care Inspection following the previous inspection, and a previous inspection requirement in regard to this documentation was judged to have been met. The service user guide document needs to be amended in regard to there being one registered manager, not two. There was neither service user guide nor statement of purpose documentation available for inspection. The registered manager reported that he was in the process of reformatting the service user guide documentation to make it more accessible, and would then supply this documentation to residents. The statement of purpose and the service user guide need to be available for inspection. The registered person needs to supply each resident with a copy of the service user guide. Primrose House Nursing Home DS0000022936.V257029.R01.S.doc Version 5.0 Page 9 The care home has an admission policy/procedure, emergency admission procedure. This procedure is recorded in the service user guide documentation supplied to the CSCI. Care plans inspected recorded evidence that prospective residents had received assessment of their needs by the provider. A care plan inspected informed the inspector that a resident referred through Care Management arrangements had their needs assessed by the relevant purchasing authority. Staff reported that if a prospective resident is unable to visit the care home prior to their admission, the reasons for this is documented in the care plan. Primrose House Nursing Home DS0000022936.V257029.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 7,8 and 9 Arrangements are in place to ensure that resident’s health needs are met. Appropriate policies and procedures are in place to ensure that medication is administered safely. EVIDENCE: All the residents have an individual plan of care. These care plans recorded evidence of having been regularly reviewed. The inspector was informed that the care plan format had recently been reviewed. This has generally improved the accessibility of the information. The four care plans inspected recorded evidence of comprehensive assessment of individual residents needs, including assessment of individual personal care needs of residents. Recorded staff guidance is in place to ensure that these assessed needs are met. Records informed the inspector that some staff guidance had been further developed since the previous inspection. Records confirmed that residents receive nutritional risk assessments. Staff action guidance from these needs further development. This was discussed with Mrs Cader. The inspector was informed of the number of residents who had a pressure sore, and staff reported that advice and support from the tissue viability nurse is obtained regularly. Records in regard to pressure sore information recorded in a care plan inspected differed from verbal information supplied to the Primrose House Nursing Home DS0000022936.V257029.R01.S.doc Version 5.0 Page 11 inspector by a senior staff member. The registered person needs to ensure that there are appropriate systems in place to ensure that correct agreed information in regard to a resident is recorded in the care plans. Observation, staff, and records confirmed that equipment necessary for the prevention and treatment of pressure sores is provided to residents. Care plans inspected included documentation in regard to risk assessment of falls, nutritional risk assessment and risk of pressure sores. The registered person should regularly review the incidence of falls and record this review and the staff action taken to minimise the risk of falls. Specialist advice should be sought in regard to minimising the risk of falls. This was discussed with Mrs Cader. Information in regard to this was supplied by the inspector to the registered person following the inspection. All the residents are registered with a GP. Records confirmed that the GP visits the care home regularly. The registered person should review the recording procedures in regard to resident’s care, and treatment from other health care services such as dentist, optician, chiropodist and tissue viability nurse. Information in regard to these contacts was not easily accessible. Staff guidance in regard to a change in the way in which a resident obtained her nutrition, and fluids since returning from hospital needs to be recorded in the care plan and the relevant nutritional assessment, and staff guidance reviewed and up dated. Service users preferred term of address, was recorded in the care plans inspected. Resident’s weight is monitored; the registered person has recently provided the care home with new weighing scales. Staff were observed to respect service users’ privacy and dignity during the inspection. There was some recorded evidence that residents had the opportunity to participate in exercise sessions. It is recommended that this activity be offered to residents daily. The care home has an accessible payphone. The care home has an accessible medication policy. Medication is stored securely. Records are kept of all medication received from the pharmacist. Registered nurses administer the medication. Records informed the inspector that the pharmacist regularly visits the care home. Some prescribed eye drops had not been disposed of on the required date. The registered person needs to ensure that medication is disposed of according to instructions from the pharmacist. Primrose House Nursing Home DS0000022936.V257029.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 12 Arrangements are in place for residents to have the opportunity to participate in activities. EVIDENCE: Records inspected recorded that residents participated in activities. These included spending time in the garden during the warm weather, going to the pub, listing to music, television, accessing a library service, and reminiscence activities. Residents were observed to participate in playing ball, bingo, reading newspapers, and watching television during the inspection. The registered person informed the inspector that a Christmas party was in the process of being planned. Activities in regard to residents who have dementia care needs were discussed with the registered person. The registered person should consult specialist organisations in regard to obtaining advice regarding the provision of activities for residents with these particular needs. Staff informed the inspector that residents have the opportunity for religious observance, and that they were in the process of trying to access input to the service from other places of worship. Records including the visitor’s record book, also a resident, and a visitor confirmed that residents receive visitors. A visitor spoke of visiting a relative regularly at different times of the day, and was very satisfied with the service provided. Primrose House Nursing Home DS0000022936.V257029.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 16 and 18 Arrangements are in place to ensure that complaints are listened to, taken seriously and acted upon appropriately. There needs to be development in the homes’ adult protection procedure to ensure that a proper response to any suspicion or allegation of abuse EVIDENCE: The care home has a complaints procedure. It is recorded in the service user guide documentation, and it specifies how complaints may be made, and the timescales in which they are responded to. There have been no recorded complaints since the last inspection. The home has a protection of vulnerable adults procedure. This needs to be amended to ensure that it is in line with local authority adult protection procedures. This was discussed with staff. This was a previous requirement. Residents need to have evidence that individual financial risk assessments are in place. This was discussed with the registered person, and was a previous requirement. Staff who spoke with the inspector had knowledge and understanding of reporting procedures in regard to a suspicion of abuse. Records informed the inspector that staff had recently received elder abuse awareness training. Records confirmed that a Criminal Records Bureau check had been obtained in regard to a cook. The registered person reported that a CRB check for the domestic staff and another cook had been applied for. The registered person needs to supply the Commission for Social Care Inspection with recorded evidence that Criminal Record Bureau checks for these staff have been obtained. Primrose House Nursing Home DS0000022936.V257029.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 19 and 26 The location and layout of the care home is suitable for its stated purpose. Arrangements are in place to ensure that the care home is kept clean. EVIDENCE: The home is located in Harrow Weald, within a few minutes drive or walk from shops and other amenities, and public bus and train transport facilities. A tour of the premises took place during the unannounced inspection. There was evidence that some redecoration of communal areas had taken place since the last inspection, and that some carpets in the communal areas have been replaced. A shower has been installed on the ground floor. The registered person should continue to improve the décor within the care home and aim to make the environment more homely, and to also assess, and repaint some areas of the care home including resident’s rooms, and communal areas. The garden is enclosed and maintained. There was evidence of garden furniture. Residents spoke of spending time in the garden during the summer. An area of exposed ceiling plaster located in a resident’s room needs painting (17). Primrose House Nursing Home DS0000022936.V257029.R01.S.doc Version 5.0 Page 15 A cracked area near the washbasin of a resident’s room (19) needs repair. There is a domestic staff member employed. The care home is clean, and free from offensive odours. The laundry facilities are located away from food storage, and food preparation areas. Carpets located in several residents’ rooms, and in some communal areas were stained, and need cleaning or replacing. This was discussed with senior staff. The registered person needs to ensure those paper hand towel dispensers are kept full. Paper towels should be used rather than cotton/towelling hand towels to ensure that the risk of infection is minimised. Staff were observed wearing appropriate protective clothing, which included gloves and aprons. The extractor fan in the laundry needs cleaning. Mrs Cader informed the inspector that all staff have plans to complete a three month infection control college course. Primrose House Nursing Home DS0000022936.V257029.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 27,28, and 30 Arrangements are in place to ensure that the number, and skill mix of staff on duty during the day enable needs of service users to be met. Review of staffing needs at night should be on going. Arrangements are in place to ensure that staff receive appropriate training including NVQ care training, to ensure that they have knowledge and skills to carry out their job role. EVIDENCE: The staff rota was available for inspection. During the day there are generally four care staff, and a registered nurse, and a cook, and domestic staff on duty. A visitor reported that there were judged to be sufficient staff on duty, when visits take place. Mr and Mrs Cader are generally on duty during the weekdays, and are available for advice at other times. The staff rota should include a record of the time allocated for staff ‘handover’. Mrs Cader informed the inspector that there was time allocated for staff ‘handovers’ to take place, but this should be evident on the staff rota. This was discussed with Mrs Cader. Records confirmed that staffing levels are adjusted to meet the needs of service users in the evenings. The registered person should ensure that staffing levels at night are under constant review, particularly in regard to residents with changing needs, and those with dementia care needs. Staff, and records confirmed that staff receive an induction programme, and that appropriate training is provided for staff. The inspector was informed by staff, and records that all staff had recently completed a TOPSS foundation ‘working in care induction course. The induction programme includes Primrose House Nursing Home DS0000022936.V257029.R01.S.doc Version 5.0 Page 17 understanding principles of care and policies and procedures, and shadowing more experienced staff. The registered person informed the inspector of some recent staff training, which included abuse awareness, manual handling training, risk assessment training, and food and hygiene training. Staff reported that they received comprehensive training, and refresher training. Mrs Cader reported that she monitors staff to ensure that they carry out appropriate and safe manual handling procedures. The inspector was informed by staff that dementia care training for all staff was planned to commence in December2005, and that there were plans for all staff to complete an infection control course. The registered person reported that a staff member was in the process of completing an NVQ level 2 care course, another was completing an NVQ 3 care course, and that four staff were planning to commence NVQ care training in November 2005. A staff member spoke of having obtained an NVQ level 3 in care qualification. The registered person should ensure that NVQ care training for staff continues to be accessible, and is achieved by all care staff. The registered person informed the inspector that the care home has several adaptation nurse students completing placements in the care home. The registered person needs to ensure that there is clear recorded guidance from the registered person, regarding the role of the adaptation students, and what they are permitted (or not permitted) to do within the care home. This was required following the previous inspection. Some guidance from the college providing the placements was available for inspection. Residents, records, and staff informed the inspector that staff had knowledge and understanding of their job role. A resident spoke of staff having understanding of her needs and of staff being approachable and kind. Primrose House Nursing Home DS0000022936.V257029.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 35 and 38 Residents do not have their finances managed by the service provider. Their monies are managed by relatives/significant others. Arrangements are generally in place to ensure that the health, safety and welfare of and staff are promoted and protected. EVIDENCE: The care home has a residents’ financial policy/procedure. The registered person informed the inspector that presently no residents have their monies managed by staff. (See Standard 18 in regard to the need for individual resident’s financial risk assessment.) The required health and safety poster was displayed. Policies and procedures in regard to health and safety were available for inspection. Fire action guidance was accessible, and clearly exhibited. Appropriate fire checks and fire training are carried out, and a fire risk assessment is in place. A resident had her bedroom door wedged open. There needs to be an appropriate Primrose House Nursing Home DS0000022936.V257029.R01.S.doc Version 5.0 Page 19 mechanism in place (that meets fire safety procedures) to enable a resident to keep her bedroom door open during the day. Until then the door of the room must not be wedged open. Advice needs to be sought from the fire service. This was discussed with senior staff. The registered person informed the inspector that ten staff have recently received manual handling training from a physiotherapist, and that they were awaiting their training certificates. Required checks of the hoist had been completed. The inspector was informed that water chlorination checks had been carried out during the week of the inspection and that he was awaiting a certificate confirming that the water systems were safe. Required gas checks were satisfactory and up to date. Fridge and freezer temperatures, and hot water temperatures are monitored. There needs to be clear recorded staff guidance, and risk assessment in regard to the use of stair gates in the care home. This should incorporate the health and safety aspect of their use, and include the issue of their use being a possible form of restraint. There needs to be a thermometer in place located near the conservatory /extension section of the communal sitting/dining room to monitor the temperature of that environment so as to minimise risk to health and safety of residents. A rug located in resident’s room (10) was curled up at the edges. This could be a trip hazard. The registered person needs to ensure that the risk of tripping from this rug is minimal. Primrose House Nursing Home DS0000022936.V257029.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 Primrose House Nursing Home DS0000022936.V257029.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4, 5(2) • Requirement The statement of purpose and the service user guide need to be available for inspection. • The registered person needs to supply each resident with a copy of the service user guide. • The service user guide document needs to be amended in regard to there being one not two registered managers. The registered person needs to ensure that there are appropriate systems in place to ensure that correct information in regard to a resident is recorded in the care plan. . Staff guidance in regard to a change in the way in which a resident obtained her nutrition and fluids since returning from hospital needs to be recorded in the care plan and the relevant nutritional assessment and staff guidance reviewed and up dated. The registered person needs to ensure that medication is DS0000022936.V257029.R01.S.doc Timescale for action 01/12/05 2. OP8 12,14, 15 01/12/05 3. OP8 12 01/12/05 4 OP9 12 13(2)(4) 14/11/05 Primrose House Nursing Home Version 5.0 Page 22 5. OP18 13 (6) 6. OP18 13(6) 7 OP18 13(6) 19 8 OP19 23(2) 9 OP26 23(2) 9 OP27 13(4)(6) 10 OP38 23(4) disposed of on the required date. The adult protection policy needs to record the need to follow the Local Authority protection of vulnerable adult procedures following an allegation of abuse, prior to an investigation. Previous timescale of 01/08/05 not met. Service users financial risk assessments need to be in place. Previous timescale 01/09/05 not met. The registered person needs to supply the CSCI with recorded evidence that Criminal Record Bureau checks have been obtained for a cook and a domestic staff member. • An area of exposed ceiling plaster located in a resident’s room needs painting (17). • A cracked area near the washbasin of a resident’s room (19) needs repair. • Carpets located in several residents’ rooms, and some communal areas were stained, and need cleaning or replacing. • The registered person needs to ensure that paper hand towel dispensers are kept full. • The extractor fan in the laundry needs cleaning. The registered person needs to ensure that there are in house guidelines developed and in place in regards to seconded students, (and their role). Previous timescale 01/08/05 not met. There needs to be an appropriate mechanism in place (that meets fire safety procedures) to enable a resident to keep her bedroom DS0000022936.V257029.R01.S.doc 01/12/05 01/12/05 01/01/06 01/01/06 01/01/06 01/12/05 01/01/06 Primrose House Nursing Home Version 5.0 Page 23 11 OP38 12 13(4)(7) 12 13(4) 23 (2)(p) 12 OP38 13 OP38 12 13(4) door open during the day. Until then the door of the room must not be wedged open. Advice needs to be sought from the fire service. There needs to be clear recorded staff guidance, and risk assessment in regard to the use of stair gates in the care home. There needs to be a thermometer in place located near the conservatory /extension section of the building to monitor the temperature of that environment to minimise risk to health and safety of residents. A rug that is a possible risk hazard needs to be assessed and action taken by the registered person to ensure that the risk is minimal. 01/01/06 01/12/05 01/12/05 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 OP8 Good Practice Recommendations The registered person should regularly review the incidence of falls and record this review, and the staff action taken to minimise the risk of falls. • Specialist advice should be sought in regard to minimising the risk of falls. The registered person should review the recording procedures in regard to resident’s care and treatment from other health care services such as dentist, optician, chiropodist, and tissue viability nurse and others. It is recommended that exercise sessions be offered to residents daily. The registered person should consult specialist organisations in regard to obtaining advice regarding the provision of activities for residents with particular needs, such as dementia care needs. DS0000022936.V257029.R01.S.doc Version 5.0 Page 24 • 2. OP8 3. 4 OP8 OP12 Primrose House Nursing Home 5 OP19 6 7 OP26 OP27 The registered person should continue to improve the décor within the care home, and aim to make the environment more homely, and to assess and repaint some areas of the care home including resident’s rooms and communal areas. . Paper towels should be used rather than cotton/towelling hand towels to ensure that the risk of infection is minimised. • The registered person should ensure that staffing levels at night are under constant review, particularly in regard to residents with changing assessed needs and dementia care needs. • The staff rota should include a record of the time allocated for staff ‘handovers’. Primrose House Nursing Home DS0000022936.V257029.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: 0845 015 0120 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 Nursing Home DS0000022936.V257029.R01.S.doc Version 5.0 Page 26 - 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. 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