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Inspection on 27/04/06 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 27th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 care home has a welcoming atmosphere. Residents spoke of staff being helpful, and kind. Staff receive varied and appropriate staff training to ensure that they have the skills, competency and knowledge to meet resident`s varied needs. Staff have a good knowledge and understanding of resident`s needs. Records are well maintained and kept up to date. The registered manager/provider works hard to meet inspection requirements, and is keen to continue to improve the service provision. Feedback comment cards from relatives, health and social care professionals were positive about the care home. Recorded feedback from some visitors described staff as `very helpful and caring`, and `friendly`.

What has improved since the last inspection?

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 Key Unannounced Inspection 27th April 2006 08:30 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.V287529.R01.S.doc Version 5.1 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.V287529.R01.S.doc Version 5.1 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.V287529.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Maximum of 23 elderly persons over the age of 65 in need of general nursing care Minimum staffing notice applies 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. 13th October 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. . 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 range of fees is £560-£700 week. Information and documentation about the service is available from the care home. 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.V287529.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place throughout 6.5 hours during a day in April 2006. The inspector was pleased to meet, and speak with most of the residents, some relatives/visitors, a GP, and several staff on duty. The purpose of the inspection was to spend time with the residents, and to gain their views of the service, assess key standards, and to follow up and assess as to whether previous inspection requirements and recommendations had been met. The inspection included a tour of the premises, inspection of resident’s care plans, staff personnel records, medication storage and administration records, meals and mealtimes, and inspection of a variety of other records. The registered manager/provider had supplied the Commission for Social Care Inspection pre inspection information and documentation, which considerably assisted the inspector in the process of inspection. The inspector spent a significant part of the inspection talking with all the residents, and observing interaction between residents and staff. Several residents’ communication skills were varied, and many had difficulty communicating their views of the service, so observation was a major tool in the inspection process. 5 feedback/comment cards were received from residents, 5 from relatives/visitors and 7 from health and social care professionals. The registered manager/proprietor was present during the inspection. Staff kindly provided all the information, and documentation requested by the inspector during the inspection. A notice was displayed in the care home that documentation and information in regard to the service provided by the care home is available from the nurse in charge. Key National Minimum Standards were assessed during the inspection and requirements from the previous inspection were judged as having been met. What the service does well: The care home has a welcoming atmosphere. Residents spoke of staff being helpful, and kind. Staff receive varied and appropriate staff training to ensure that they have the skills, competency and knowledge to meet resident’s varied needs. Staff have a good knowledge and understanding of resident’s needs. Records are well maintained and kept up to date. The registered manager/provider works hard to meet inspection requirements, and is keen to continue to improve the service provision. Feedback comment cards from relatives, health and social care professionals were positive about the care home. Recorded feedback from some visitors described staff as ‘very helpful and caring’, and ‘friendly’. Primrose House Nursing Home DS0000022936.V287529.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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.V287529.R01.S.doc Version 5.1 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.V287529.R01.S.doc Version 5.1 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 2,3 (6 not applicable) Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Residents receive a written statement terms and conditions/contract when they move into the care home. Arrangements are in place to ensure that prospective residents to the care home receive an assessment of their needs. EVIDENCE: Residents have a written statement of terms and conditions/contract when they move into the care home. This includes information in regard to the fees and charges for extras, such as hairdressing, and newspapers. The care home has an admission procedure. The registered person informed the inspector that prospective residents are generally referred to the service by a care manager (some residents are privately funded). The registered person will then assess the prospective resident. This may take place in hospital or at the resident’s home. The registered person confirmed that the prospective resident and their relatives/significant others are involved in this process. The Primrose House Nursing Home DS0000022936.V287529.R01.S.doc Version 5.1 Page 9 registered person reported that prospective residents are given a questionnaire in regard to their preferences, (such as their preferred activities) prior to their admission. Two relatives confirmed that they had been involved in this process of assessment. A relative spoke of having visited the care home prior to their relative moving into the care home. The registered person spoke of prospective residents being encouraged to have a lunch visit with other residents prior to their admission. From the initial assessment the residents care plan is developed. The care plans inspected confirmed evidence of assessment. Care managers also complete an assessment of the prospective residents needs. The registered person confirmed that all the residents have a copy of the service user guide documentation in regard to the service provided by the care home. Primrose House Nursing Home DS0000022936.V287529.R01.S.doc Version 5.1 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 7,8,9, and 10 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that all residents have an individual plan of care, and that resident’s health and their personal care needs are met. Medication is stored and administered safely. EVIDENCE: All residents have a plan of care. Four care plans were inspected. These included a personal history of the resident and comprehensive assessment information in regard to residents needs. This assessment included manual handling assessment, nutrition assessment, pressure area risk assessment and risk of falls. There needs to be recorded staff guidance/risk assessment in regard to staff meeting the needs of residents that need to be assisted with feeding by staff. This was discussed with the registered person. Some ‘swallowing’ guidance was recorded and displayed in the kitchen. The care plans are accessible to staff, and records confirmed that the care plans are reviewed on a monthly basis. The care plan documentation is accessible to staff and staff were observed updating care plans and recording individual daily progress records. Staff who spoke with the inspector had Primrose House Nursing Home DS0000022936.V287529.R01.S.doc Version 5.1 Page 11 knowledge and understanding of the care plans, and they complete daily records of each resident’s progress. Records and a resident confirmed that residents have the opportunity to access healthcare specialists such as an optician, dentist, psychiatrist, tissue viability nurse, chiropodist, and hospital appointments. The registered person informed the inspector that all residents are registered with a GP. A GP visited that care home during the inspection and spoke positively about the service provision. A resident who kindly spoke to the inspector was aware that the GP was planning to see her on the day of the inspection. Health records are recorded in the care plans, and resident’s weight is monitored. Pressure relieving equipment was observed to be accessible to residents. Some residents were observed to use wheelchairs and others received assistance from staff with meeting their mobility needs. Written feedback from 5 residents informed the inspector that the residents felt well cared for, and 5 relatives/significant others were positive about the care provision. Staff were observed during the inspection to be respectful towards residents and to have an understanding of the residents privacy needs. A resident spoke of wearing her own clothes at all times. The issue of reviewing some aspects of some residents clothing (some residents, with significant needs wore short ‘pop socks’ with dresses or skirts, which might cause tightness around residents calves) was discussed with a senior staff member of staff. The registered person confirmed that residents open their personal mail (at times with support from staff), and that staff are informed of the preferred form of address of residents during staff induction, and how to ensure that residents are treated with respect at all times. The registered person reported that the care home’s charter of rights had recently been reviewed. The medication storage and administration systems were inspected. Trained nurses administer medication. The medication policy/procedure was accessible. A sample of medication administration records were inspected and were fully recorded. Medication was stored securely. A registered nurse informed the inspector that the GP reviews the medication of residents on a fortnightly basis. Recorded feedback from a pharmacist was positive in regard to the care home’s administration of medication. Primrose House Nursing Home DS0000022936.V287529.R01.S.doc Version 5.1 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, 13,14 and 15 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that residents have the opportunity to participate in some activities, but these need to be further developed. Residents are supported in maintaining contact with family/significant others, and are supported in making decisions about their lives. Meals provided are varied and wholesome. EVIDENCE: Records confirmed that residents are given the opportunity to participate in some activities. These included watching television, reading the newspaper, music and playing ball. These activities were recorded to be the main general activities provided to residents. Some residents joined in a bingo session during the inspection. Recorded feedback from a resident, and verbal feedback from a resident informed the inspector that there were not enough suitable activities. During the inspection there was not evidence of varied activities to meet individual varied needs, some residents sat in chairs, with no evidence of any participation in an activity. There needs to be development in the provision of activities for all residents, to contribute in ensuring that signs of well being amongst the residents are increased. The registered person should ensure that residents have the opportunity to participate in exercise sessions that meet their varied needs. Information and advice should be Primrose House Nursing Home DS0000022936.V287529.R01.S.doc Version 5.1 Page 13 sought from charities/specialists in regard to meeting the activity needs of those who have dementia care needs. In regard to feedback from visitors, the registered person should consider ways of improving the environment in which residents participate in religious services. Residents kindly spoke of receiving visitors. Records confirmed that the care home has frequent visitors. A friend of a resident spoke of visiting regularly at varied times, and that staff were always approachable. Two visitors spoke of how some resident’s religious needs are met. The registered person should consider ways of improving the environment in which residents participate in religious services. A visitor confirmed that the cultural needs of their friend were met. Staff informed the inspector of examples of how the care home meets cultural and religious needs of residents. Residents have access to a telephone. A resident spoke to their relative on the telephone during the inspection. There was evidence that residents are supported in making choices. Staff were observed to offer choices to residents during the inspection. Residents bedrooms that were inspected, confirmed that residents had the opportunity to bring personal possessions into the care home. A notice in regard to resident meetings was displayed. The menu was available for inspection. Meals recorded were judged to be wholesome and varied. Lunch during the inspection matched the recorded menu, and condiments were offered to residents. Fruit was offered to residents. Two residents were observed to ask for some fruit and staff promptly provided this. The cook was aware of the specialist dietary needs of residents. Drinks were offered regularly during the inspection. The registered person should ensure that a menu is developed that is in a format that suits the capacities/needs of residents. Pictorial formats of the menu should be developed. A variety of fresh and frozen foods were accessible. Primrose House Nursing Home DS0000022936.V287529.R01.S.doc Version 5.1 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 the following standard(s): Standard 16,18 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that there is a complaints procedure, which ensures that residents and their relatives are confident that complaints will be taken seriously. Ways of ensuring that residents are aware of the complaints procedure need development. Arrangements are in place to ensure that residents are protected from abuse. EVIDENCE: The complaints procedure was displayed in the care home. Recorded feedback from 5 relatives/significant others recorded that they were aware of the procedure for making a complaint. Recorded feedback from 4 residents indicated that they were unsure of whom to speak to if they had a concern/complaint. The registered person needs to ensure that all residents are aware of who they can speak to if they are dissatisfied/unhappy about something. Appropriate complaint recording procedures are in place. The care home has a Protection of Vulnerable Adults policy/procedure, and the Local Authority procedure. The registered person reported that he trained staff in the protection of vulnerable adults, and that staff were informed of abuse awareness during their induction programme. Staff who spoke with the inspector had knowledge and understanding of protecting residents from abuse. The care home has recorded financial procedures, and a whistle blowing policy/procedure. Primrose House Nursing Home DS0000022936.V287529.R01.S.doc Version 5.1 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 the following standard(s): Standard 19 and 26. Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Residents live in a safe, clean, and generally well maintained environment. EVIDENCE: The care home has parking for several cars on its forecourt. It is located within a few minutes drive or walk from Harrow Weald, in which there are a variety of amenities and public transport facilities. The inspection included a tour of the premises. Rooms within the home are naturally ventilated, and centrally heated. Radiators are covered. There has been some development in regards to improving the décor and furnishings within the care home. The carpet has been replaced in some communal areas on the ground floor, and the décor in the corridors of the home has been improved. The registered person spoke of plans to improve other areas of the care home including the kitchen, and the lighting in the sitting room. These improvements should take place; the registered person should continue to consider ways to improve the general décor of the sitting room, and to improve the ‘homeliness’ of the care home. Primrose House Nursing Home DS0000022936.V287529.R01.S.doc Version 5.1 Page 16 Two armchairs located in the sitting room need to be cleaned or replaced. The net curtains in the sitting room are thick and hinder the light. The registered person should consider changing these. There is an accessible enclosed garden. The home was clean and an air freshener system has been installed since the last inspection. Domestic staff are employed. Soap and paper hand towels are generally accessible, but there was not any soap in the shower room. The registered person reported that hand dryers are to be installed throughout the home. The registered person reported that the home has recently installed an air deodoriser system. The laundry facilities are located away from food storage and food preparation areas. Primrose House Nursing Home DS0000022936.V287529.R01.S.doc Version 5.1 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 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 27,28,29, and 30 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that the numbers and skill mix of staff meet the resident’s varied needs, and that staff recruitment procedures ensure that residents are supported and protected. Staff receive appropriate training to enable them to carry out their roles and responsibilities in meeting residents varied needs. EVIDENCE: Recorded and verbal feedback from residents was complimentary about the staff, and the care that they received from them. Visitors were positive about the staff, and spoke of them being very approachable. During the day there are four care staff plus a trained nurse and a domestic staff member and cook on duty. There is a trained nurse and a care staff member on duty at night. The staff numbers from 8pm was discussed with the registered person, and he agreed that it would be appropriate for a care staff member to work until 9pm. The home has several nurse adaptation staff that work in the home. The registered person confirmed these staff provided extra staffing and skills for the care home, and that extra staffing was provided at certain times to meet the needs of the residents. 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. Feedback comment cards from relatives were positive about the staff and described staff as ‘very helpful and caring’, and ‘friendly’. Primrose House Nursing Home DS0000022936.V287529.R01.S.doc Version 5.1 Page 18 The registered person informed the inspector that three care staff were in the process of completing NVQ level 2 or 3 in care, and that two staff members were planning to commence NVQ care courses. Four staff personnel files were inspected. These contained required information and documentation including enhanced Criminal Record Bureau checks. Staff who spoke with the inspector confirmed that they received induction training, and supervision. Records and staff confirmed that they received varied and appropriate training to ensure that they can meet the needs of the residents. This training includes ‘in house’ training. There is also training completed by external trainers. The registered person reported that staff complete the Skills for Care Common Foundation induction course and that several staff are in the process of completing a dementia care training course. Training included, manual handling training, infection control training, basic first aid, skin care, health and safety training, risk assessment training, and basic food and hygiene training, wound dressing update for nurses. Staff files included staff training documentation. Senior staff confirmed that nursing staff are being supported to develop their skills and responsibilities to enable them to manage a variety of care issues competently when the registered person is away. Primrose House Nursing Home DS0000022936.V287529.R01.S.doc Version 5.1 Page 19 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): Standard 31,33, 35 and 38 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The care home is being managed appropriately, and that the service is monitored to ensure that resident’s needs are met, and that the health, safety and welfare of staff and residents are protected. EVIDENCE: The manager is a registered general nurse, and registered mental health nurse and has managed and run the care home for several years. He completes most of the staff ‘in house’ training, and has a management qualification, and is planning to commence NVQ level 4 in management this year. Records confirmed that the registered person updates his skills by undertaking periodic training. The registered manager/provider informed the inspector that he had recently commenced ‘mentoring in the workplace’. Feedback from visitors and a resident confirmed that the manager was approachable, and that they were kept informed of changes in their relative’s/friends condition. Evidence from Primrose House Nursing Home DS0000022936.V287529.R01.S.doc Version 5.1 Page 20 speaking to residents, visitors and staff confirmed that there are clear lines of accountability within the home. Systems for monitoring the quality of the service are in place. These include reviewing records, care plans and staff training needs. The registered person spoke of being in the process of completing an annual development/business plan for the care home, and that questionnaires would be given to residents and visitors/relatives. The registered person shall supply to the Commission for Social Inspection a report/annual development plan in respect of any review conducted by him. Staff meetings and resident meetings take place. The care home manages small sums of resident’s monies. Resident’s financial affairs are managed by family members, and care managers. Records are maintained of expenditure and those inspected were found to be in good order. Required checks of the electrical and gas systems are carried out. Fire checks, staff fire training and drills are carried out regularly. The home has recorded fire action guidance, which is displayed in the care home. Records confirmed that wheelchairs were regularly checked for faults. Specialist baths and hoists receive required checks. Primrose House Nursing Home DS0000022936.V287529.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 2 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 3 X 3 X 3 X X 3 Primrose House Nursing Home DS0000022936.V287529.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 12, 13(4) 16, 18 Requirement There needs to be recorded staff guidance/risk assessment in regard to staff meeting the needs of residents that need to have assistance with feeding by staff. The registered person needs to consult residents about the programme of activities arranged by the care home, and develop the provision of activities particularly in relation to recreation and fitness, well being, and in regard to the varied needs of residents. The registered person needs to ensure that all residents are aware of the complaints procedure. Two armchairs located in the sitting room need to be cleaned or replaced. There needs to be soap in every bathroom/shower room. The registered person shall supply to the Commission for Social Inspection a report/annual development plan in respect of any review conducted by him, DS0000022936.V287529.R01.S.doc Timescale for action 01/09/06 2 OP12 12,13,16 (m)(n) 01/09/06 3 OP16 22(5) 01/09/06 4 5 6 OP19 OP26 OP33 23(2) 16(2) 24(2) 01/08/06 01/08/06 01/09/06 Primrose House Nursing Home Version 5.1 Page 23 which includes seeking the views of residents and others. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP10 OP12 OP12 Good Practice Recommendations The registered person should (with residents involvement) look in to the appropriateness and risk of residents wearing ‘pop socks’. The registered person should consider ways of improving the environment in which residents participate in religious services. The registered person should ensure that residents have the opportunity to participate in exercise sessions that meet their needs. Information and advice should be sought from specialists/charities in regard to meeting the activity needs of those who have dementia care needs. The registered person should ensure that a menu is developed that is in a format to suit the capacities/needs of residents. Pictorial formats should be considered. • The improvements in the lighting in the sitting room, and the kitchen maintenance, should take place, the registered person should continue to consider ways to improve the general décor of the sitting room, and to improve the ‘homeliness’ of the care home. • The net curtains in the sitting room are thick and hinder the light. The registered person should consider changing these. The registered person should ensure that there is another care staff on duty in the evenings to assist night staff in helping residents to bed. 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’. 4 5 OP15 OP19 6 7. OP27 OP27 Primrose House Nursing Home DS0000022936.V287529.R01.S.doc Version 5.1 Page 24 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.V287529.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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