CARE HOMES FOR OLDER PEOPLE
Primrose Lodge Lingdale East Goscote Leicestershire LE7 3XW Lead Inspector
Helen Abel Announced 31 May 2005, 10:00am
st The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Primrose Lodge C51 S1700 Primrose Lodge V223151 310505.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Primrose Lodge Address Lingdale East Goscote Leicestershire LE7 3XW 0116 2697871 0116 2697871 None Mr John Nunn & Mrs Barbara Nunn Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Samantha Bacon Care Home 15 Category(ies) of Old age (15), Physical disability over 65 years of registration, with number age (4) of places Primrose Lodge C51 S1700 Primrose Lodge V223151 310505.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 1st November 2004 Brief Description of the Service: Primrose Lodge is one of fifteen homes owned by Mr and Mrs Nunn. The Registered Providers set up the Broadoak Group of Care Homes in 1986. Mr and Mrs Nunn have over 17 years in providing nursing and residential care.The home provides care for fifteen older people. There are fifteen single rooms all with en-suite all on one level. A large lounge with separate dining area. There are landscaped gardens and an attractive area at the front of the home where service users may sit on benches. Choice of menu and special diets are available. The home provides some recreational facilities and day trips out. There is a cat called Sweep living in the home.The home is set in a residential area, a short distance away are shops and access to public transport. Opposite Primrose Lodge is another residential home Lingdale Lodge. This is also owned by the Broadoak Group of Care Homes. The home’s full catering needs are provided at Lingdale and transported across to Primrose each mealtime. Primrose Lodge C51 S1700 Primrose Lodge V223151 310505.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This statutory announced inspection took place over a period of 3 hours. The Registered Provider and Registered Manager were present throughout the inspection. The care of two service users was reviewed and this included looking at their care records, care plans, assessments and their medication. The residents in the communal areas of the home were observed to be relaxed and calm. The residents in the home are older people. All residents spoken to were able to comment about how they felt living in the home. What the service does well:
Residents are supported in attending daily activities quiz, bingo, and skittles. There is also a range of summer trips being arranged over the forthcoming months. A resident confirmed the Registered Manager and staff are very friendly. Family and friends are welcomed at the home with hot drinks. Staff have undertaken a range of protecting adults from abuse training, which remains ongoing. Established protecting adults policies and procedures are in place to safe guard residents. Maintenance issues are up to date in the home. The Registered Provider confirmed any urgent maintenance aspects are always dealt with immediately once reported on. All areas inspected at the home appeared clean and hygienic. As part of a quality audit the Registered Manager annually formally writes to residents and their relatives for feedback on the service. A newsletter is produced for residents that highlight the outcome of the feedback, as well as information about the home, and any planned events and celebrations. Primrose Lodge C51 S1700 Primrose Lodge V223151 310505.doc Version 1.30 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 Lodge C51 S1700 Primrose Lodge V223151 310505.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Primrose Lodge C51 S1700 Primrose Lodge V223151 310505.doc Version 1.30 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 standard(s) 1 & 3 There is printed Statement of Purpose avaible to prospective residents. A written assessment always takes place before a resident enters the home. EVIDENCE: The Statement of Purpose was evident in the home and was user friendly with bold and colourful text. The Registered Provider agreed he would include the correct full title of the Commission for Social Care Inspections in the home’s Statement of Purpose. A copy of the last inspection report was also available in the main foyer. Resident’s assessments were completed for new residents coming to live in the home. The assessment format should be updated to include the date the inspection took place and the names of people present at the assessment. Primrose Lodge C51 S1700 Primrose Lodge V223151 310505.doc Version 1.30 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 There is a shortfall around consultation when producing resident’s health and personal care plans. Resident’s health care needs are fully met. Residents are treated respectfully and their right to privacy upheld. EVIDENCE: Care plan documentation is comprehensive. Care plans sampled were not agreed and signed by residents or their relatives. The Registered Manager reported the practice was for new care plans to be explained to residents. Risk assessments were in place and set out the minimising of risks for individual residents. The records indicated that access to healthcare professionals was facilitated, as were visits to other specialists. Residents are weighed bi-monthly with a written record of their weight held on their care plan. The medication storage areas and medication records were well organised. A photograph of each resident is held with their medicine records in order to reduce the risk of misadministration of medicines.
Primrose Lodge C51 S1700 Primrose Lodge V223151 310505.doc Version 1.30 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 There are sufficient social, cultural, religious and recreational interests to meet the expectations and preferences of residents. Residents who wish to maintain contact with family and friends have good opportunities to do so. Residents are given sufficient help to exercise choice and control over their lives. Residents receive a wholesome and appealing diet in pleasant surroundings. EVIDENCE: Residents are supported in attending daily activities quiz and bingo and there is a range of summer trips being arranged over the summer months to Stratford and Skegness. A recent day trip out was on a boat in Nottingham. Religious ceremonies are conducted at the adjacent Lingdale Lodge a Broadoak home opposite Primrose. Staff escort residents across to enjoy a service in one of their communal areas. A resident confirmed the Registered Manager and staff are very friendly. Family and friends are welcomed at the home with hot drinks. The Registered Manager confirmed residents are consulted around their choice of clothes, where they wish to eat, either in their room or dining room and movement around the home. One resident had asked a staff member for her hair to be washed and set in curlers and blow dried in the lounge area.
Primrose Lodge C51 S1700 Primrose Lodge V223151 310505.doc Version 1.30 Page 11 The kitchen area is used for the light preparation of snacks and serving of meals only. The kitchen has been updated with new appliances. All meals are cooked at Lingdale Lodge the adjacent Broadoak Group home and transported over to Primrose. Lunchtime was observed with residents seated in a light bright dining area. A resident spoken to said, “The meals are very good here”. A menu was laminated and displayed but did not fully reflect the choice of meals offered. Primrose Lodge C51 S1700 Primrose Lodge V223151 310505.doc Version 1.30 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 Complaints are handled properly to provide residents with confidence that their concerns will be listened to, taken seriously and acted upon. Good policies and procedures protect residents from abuse. EVIDENCE: The home has a current detailed complaints procedure in the Statement of Purpose. An out of date complaints procedure was displayed. This needs updating and to be more prominently displayed for residents and visitors to the home. A complaints record was avaible for recording any complaints received. A resident confirmed she would happily talk to staff if she had any concerns at the home. Staff at the home have undertaken a range of protecting adults from abuse training, which is ongoing. The Registered Provider confirmed his commitment to this and other staff training. Established protecting adults policies and procedures are in place to safe guard residents. Primrose Lodge C51 S1700 Primrose Lodge V223151 310505.doc Version 1.30 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,26 Residents live in a safe, well-maintained, clean and hygienic environment. EVIDENCE: Maintenance issues are up to date in the home. The Registered Provider confirmed any urgent maintenance aspects are always dealt with immediately once reported on. Some minor aspects are outstanding in respect of a recent Environmental Health Officers visit, with the Registered Provider still dealing with this. The laundry area was well organised with separate baskets for each residents washing. All areas inspected at the home appeared safe, very clean and fresh. Primrose Lodge C51 S1700 Primrose Lodge V223151 310505.doc Version 1.30 Page 14 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Resident’s needs are met by the number and skill mix of staff. The procedures for the recruitment of staff are satisfactory and provide protection to people living in the home. Staff are trained and competent to do their jobs. EVIDENCE: The Registered Manager and core staff team are long serving and familiar with working at Primrose. There is one waking and one sleep in staff member at night. Staff left in charge of the home are all over 21 years. The deployment of staff to meet resident’s needs is satisfactory. A resident said, “The staff are very good here, help you to settle in”. A staff member’s recruitment file was sampled and found to hold two written references and had been issued a statement of terms and conditions. Criminal Record Bureau checks for all staff are up to date. All staff is working towards National Vocational Qualifications (NVQ) from Level 2 to 4. NVQ Assessors come into the home from a local college and assess staff’s care practice. In addition staff have attended a range of training from First Aid, Diabetic and Catheter care, Food Hygiene, Dementia care and others. The Registered Provider is looking to adapt new training manuals and is at the point of purchasing them. This would develop staff competence, and work towards providing an improved service for the residents. Primrose Lodge C51 S1700 Primrose Lodge V223151 310505.doc Version 1.30 Page 15 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35,38 The home is run in the best interests of residents. Resident’s financial interests are safe guarded. There is a shortfall in promoting and safe guarding the health, safety and welfare of the people using the service. EVIDENCE: As part of a quality audit the Registered Manager formally writes to residents and their relatives for feedback on the service. A yearly newsletter is produced for residents that highlight the outcome of the feedback, as well as information about the home, and planned events and celebrations throughout the year. Monies and written records held for safe keeping for two residents by the home were sampled and found to be accurate and in good order. All the required health and safety checks were generally in order. Accident reports were examined. A resident incurred a bump to her head as she came off her motorised scoter whilst outside at the local shops. This activity must be risk assessed and monitored and reviewed.
Primrose Lodge C51 S1700 Primrose Lodge V223151 310505.doc Version 1.30 Page 16 On three occasions items of cleaning materials were present in residents bathrooms. Advice was given around ensuring all cleaning materials are locked in a cupboard when not in use. Primrose Lodge C51 S1700 Primrose Lodge V223151 310505.doc Version 1.30 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x x 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 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x x 2 Primrose Lodge C51 S1700 Primrose Lodge V223151 310505.doc Version 1.30 Page 18 Yes 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 7 Regulation 15 Requirement Care plans for new residents should be explained agreed and signed by the resident (where appropiate), or their representative A risk assessment to be produced for the resident who had an accident on a motorised scoter. This should be monitored and reviewed in consultation with the resident. Timescale for action Now and ongoing 2. 38 13 Now and ongoing 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 3 Good Practice Recommendations The Needs Assessment format should include the following: date of the assessment, full name and signature of the resident (where appropiate), staff member and any other participants. Information for residents. The lunch time daily menu displayed should state the first and secand course to be served, including any other choices avaible. Provide an up to date Complaints Procedure to be displayed more prominently for residents and visitors to access in the home.
C51 S1700 Primrose Lodge V223151 310505.doc Version 1.30 Page 19 2. 3. 15 16 Primrose Lodge 4. 5. 6. 7. 38 Ensure all cleaning materials in residents bathrooms are locked away in a cupboard when not in use. Primrose Lodge C51 S1700 Primrose Lodge V223151 310505.doc Version 1.30 Page 20 Commission for Social Care Inspection Grove Park 5 Smith Way Enderby Leicestershire LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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