Inspection on 09/08/06 for Primrose Lodge

This inspection was carried out on 9th August 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.

Other inspections for this house

Primrose Lodge 23/10/07

Primrose Lodge 22/12/05

Primrose Lodge 31/05/05

Primrose Lodge 01/11/04

Primrose Lodge 18/05/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Primrose Lodge Lingdale East Goscote Leicestershire LE7 3XW Lead Inspector Ruth Wood Unannounced Inspection 9th August 2006 09:25 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 Lodge DS0000001700.V306395.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 DS0000001700.V306395.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Primrose Lodge Address Lingdale East Goscote Leicestershire LE7 3XW 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) 0116 2697871 0116 2697871 Mr John William Nunn Mrs Barbara Elsie Nunn Ms Samantha Joanne Bacon Care Home 15 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (15), of places Physical disability over 65 years of age (4) Primrose Lodge DS0000001700.V306395.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No person of category DE(E) may be admitted to the home when 6 persons with dementia are currently residing at the home No person of category PD(E) to be admitted to the home when 4 persons with physical disability are currently residing at the home 22nd December 2006 Date of last inspection Brief Description of the Service: Primrose Lodge is one of fifteen homes owned by Mr and Mrs Nunn who set up the Broadoak Group of Care Homes in 1986. Primrose Lodge provides care for fifteen older people, some who have physical disabilities and/or dementia. Accommodation is on one level and includes fifteen single en-suite rooms and a large lounge with separate dining area. There is a small kitchen for the preparation of drinks and light snacks with main meals being cooked at Primrose Lodge’s sister home, Lingdale, which is directly opposite. Outside there are landscaped gardens, together with an attractive area at the front of the home where residents can sit out when the weather permits. Day trips out are arranged and the home has a resident cat called Sweep. The home is set in a residential area with shops and access to public transport within walking distance. Fees are currently £400 per week. Primrose Lodge DS0000001700.V306395.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on a weekday between 9:25 am and 3:25 pm. A tour was made of the communal areas and the majority of residents’ rooms. As part of the inspection discussion was held with the majority of residents, staff members, the registered manager, relatives, the district nurse and the local vicar. Care practice was directly and indirectly observed and a variety of records (care, medication, staff recruitment & training, financial and maintenance) were examined. The care and support given to three residents in particular was focused upon and this included examining their care records in detail, discussing with them what it was like to live in the home (in two instances) and observation of the care they received. Prior to the inspection, questionnaires were sent to some residents, their relatives and visiting GPs. Four GP questionnaires were returned to the Commission and four completed residents’ questionnaires were given to the Inspector. What the service does well: What has improved since the last inspection? New kitchen units have been fitted. Some bedrooms, the main corridor and reception areas have been redecorated and new carpets have been laid in some bedrooms. At the residents’ suggestion the monthly church service is now held at Primrose Lodge rather than at the home directly opposite (Lingdale). Primrose Lodge DS0000001700.V306395.R01.S.doc Version 5.2 Page 6 Residents spoke positively about this and had asked for it to be moved, as they did not like going across to the other home if the weather was cold. 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 DS0000001700.V306395.R01.S.doc Version 5.2 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 Lodge DS0000001700.V306395.R01.S.doc Version 5.2 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): 1,2,3,5 Quality in this outcome area is good. Residents’ needs are comprehensively assessed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three residents’ case files were examined in detail. All contained an assessment of need completed by the registered manager, together with a comprehensive assessment completed by the resident’s commissioning social worker; contracts were also in place. The manager said that she always visited the prospective resident (at their home or hospital) to assess whether the home could meet their needs. The daughter of one of the residents confirmed that this process had taken place. Relatives spoken with stated that they had received written and verbal information about the home and had been invited to visit the home at their convenience to look around. In response to the Commission’s written survey a relative wrote, “I made a visit before my [relative] became a resident. I was given clear and precise information by the staff.” The home does not provide intermediate care; therefore standard 6 is not applicable. Primrose Lodge DS0000001700.V306395.R01.S.doc Version 5.2 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 the following standard(s): 7,8,9,10 Quality in this outcome area is good. Residents’ needs are accurately reflected in care plans; they are treated with respect and their health and medication needs are well met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three residents’ care plans were examined in detail. All contained a comprehensive plan of care, which outlined how to meet needs relating to interests and activities, mobility, continence, nutrition and communication. Discussion was held with two of the three residents and plans appeared to be an accurate reflection of their expressed and observed needs. Staff members displayed a good knowledge of the residents’ needs, which again corresponded with what was written in their respective plans. Daily records were factual and written in appropriate language. All care plans are reviewed on a monthly basis. The pressure area care needs of one resident were discussed with the district nurse who felt the home met these well. Appropriate equipment such as an airwave mattress and pressure relief cushions were in place. All residents’ pressure area care needs are regularly assessed and staff demonstrated good understanding in this area. Residents confirmed that they had regular access Primrose Lodge DS0000001700.V306395.R01.S.doc Version 5.2 Page 10 to opticians, chiropodists, doctors and dentists as and when they needed these services. The home has a policy whereby if a relative cannot accompany a resident in the event of a hospital admission, a staff member will accompany them. Medication is stored appropriately within the home and staff receive training in its administration. The lunchtime medication round was observed; residents were given appropriate drinks and were not unduly hurried. The medication record was only signed after the staff member had seen the medication taken. There is generally good practice in this area but the senior staff member did leave the medication trolley unattended, with the keys in, on two separate occasions. Medication trolleys must always be kept locked and the keys removed when not attended. Interaction between residents and staff was directly and indirectly observed throughout the inspection. At all times staff spoke to residents in a kind and respectful manner, allowing them time to reply and repeating their question if it was not initially understood. Residents, relatives and other visitors were all very positive about staff members’ attitude towards residents describing them as “very caring”, “always willing to listen” and “very patient”. Primrose Lodge DS0000001700.V306395.R01.S.doc Version 5.2 Page 11 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): 12,13,14,15 Quality in this outcome area is good. The home provides appropriate outings and activities and residents are facilitated to maintain good contact with relatives and the wider community. Good food is served in pleasant surroundings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Many residents spoke very positively about a trip to Skegness that had taken place the day before; a boat trip was planned for later in the week and some people said that they intended to go on this also. There is a plan of activities for the week and these sometimes take place during the afternoons. Residents said that they occasionally played bingo and skittles but said that they would like a bit more activity inside the house sometimes. Two visiting relatives also said that they would like to see “a bit more stimulation” inside the home. One resident commented that they found it difficult to hear and concentrate because the television was always on, even when no one was watching it. It is suggested that, following consultation with the residents, the television may be switched off for periods, particularly during meal times. Relatives said that they felt they could visit at any time and that they were always made to feel very welcome in the home. Several relatives ‘dropped in’ during the inspection as well as the local vicar who regularly visits several residents and also runs the monthly service at the home. Residents spoke Primrose Lodge DS0000001700.V306395.R01.S.doc Version 5.2 Page 12 very positively about this; one of the resident’s relatives is also actively involved in the service. The majority of the residents eat their meals in the home’s dining area, although meals can be taken in bedrooms if requested. Staff ask residents in the morning to make a choice from two main courses for lunch and one resident commented that both choices were usually very nice. All main meals are prepared at Lingdale Lodge (part of the same group) which is situated directly opposite. Drinks and snacks are prepared in the small kitchen at Primrose Lodge. Records are kept of all residents’ individual diets and fluid charts are kept for residents at risk of dehydration. Primrose Lodge DS0000001700.V306395.R01.S.doc Version 5.2 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): 16,17 Quality in this outcome area is good. Residents’ concerns are listened to and policies and procedures within the home protect them from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents and several relatives said that they would tell the registered manager or any of the staff if they were not happy and expressed confidence that any problems would be “sorted out”. One relative said that they weren’t sure if they had seen the formal complaints procedure, but this is displayed on the home’s notice board. A record is kept of any complaints or concerns raised, together with the action taken to resolve them; records were examined and issues appeared to have been dealt with appropriately. Staff have received training in adult protection and demonstrated a good understanding of issues such as what constitutes abuse and the process of whistle blowing. Robust recruitment practices ensure that staff do not start work in the home until their names have been checked against the Protection of Vulnerable Adults Register and they have undergone an enhanced Criminal Records Bureau check. Primrose Lodge DS0000001700.V306395.R01.S.doc Version 5.2 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): 19, 26 Quality in this outcome area is good. Residents live in a clean, comfortable and homely environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A full tour of the home was made. The home is well furnished and decorated with several bedrooms having recently been redecorated and new carpets fitted to some areas. The route to one fire exit was blocked by chairs; this was brought to the attention of the senior staff member and immediately cleared. On the corridor to the rear of the lounge there is a change in level which could constitute a tripping hazard for residents (as it did for the inspector). Ways of alerting residents to this or making the corridor surface even should be identified and put in place. All areas of the home were clean, tidy and fresh smelling. Information gathered from the Commission’s written survey indicates that residents felt the home was usually or always fresh and clean. Documentary evidence was available that staff had received training in infection control and staff displayed a good understanding of practice in this area, particularly in relation to MRSA. Primrose Lodge DS0000001700.V306395.R01.S.doc Version 5.2 Page 15 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): 27,28,29,30 Quality in this outcome area is good. Residents are supported by sufficient numbers of well-trained staff who have undergone robust recruitment procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Numbers of staff on duty appeared able to meet the needs of residents and the four residents who responded to the Commission’s written survey felt there were always or usually staff available when they needed them. Staffing arrangements were accurately reflected on the clearly displayed staff rota. The majority of staff have achieved a National Vocational Qualification in Care at level 2; those staff without this qualification said they are to begin their programme soon. All staff receive a formal induction and regular and ongoing training. Staff confirmed this during discussion and documentary evidence in the form of certificates was also seen. Training completed in the last twelve months has included moving and handling and the protection of vulnerable adults. Before appointment all staff complete a formal application form and undergo an interview. Two written references are requested and their names checked against the vulnerable adults register and an enhanced Criminal records bureau check obtained. Discussion with the manager, staff and examination of records confirmed this process. Primrose Lodge DS0000001700.V306395.R01.S.doc Version 5.2 Page 16 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): 31,33,35,38 Quality in this outcome area is good. Residents live in a well run home where their financial interests, health and safety are safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has managed the home for seven years. She has obtained City and Guilds Qualifications in supervisory management, a National Vocational Qualification in care at level 2 and is currently working towards her level 4. A variety of systems are in place to ensure that residents’ and relatives’ views are obtained and that these inform the way the home is run. Minutes of formal residents’ meetings showed that these are held approximately every three months and involve the majority of residents. Concerns and suggestions from residents are recorded, together with the outcome of the response to these. All residents’ relatives are written to once per year and asked for any comments or concerns they wish to raise about the running of the home; responses to these letters were examined. The manager said that together Primrose Lodge DS0000001700.V306395.R01.S.doc Version 5.2 Page 17 with these formal approaches she felt that she and the staff had a good, open relationship with residents and relatives and this was confirmed through discussion with both groups of people and observation of their interaction with each other. Residents’ relatives have overall responsibility for managing personal finances where the resident needs support. Small amounts of ‘pocket money’ are administered on behalf of residents by the home and records of monies held were checked against recorded balances and found to be accurate. All gas, electrical and fire systems have undergone routine maintenance within the last 12 months. Fire systems, alarms and emergency lighting are checked on a weekly basis, as are hot water temperatures. The temperature of baths is checked before the resident enters the water. Staff have received training in moving and handling, food hygiene, good health and safety practice and first aid. Primrose Lodge DS0000001700.V306395.R01.S.doc Version 5.2 Page 18 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 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Primrose Lodge DS0000001700.V306395.R01.S.doc Version 5.2 Page 19 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. Standard Regulation Requirement Timescale for action 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 Refer to Standard OP9 OP19 Good Practice Recommendations The medication trolley must always be kept locked and the keys removed when not attended. Ways of alerting residents to the difference in level on the identified corridor, or of making the corridor surface even, should be identified and put in place, as currently this could be a tripping hazard for residents. All fire exits must be kept free of obstruction at all times to ensure safe passage for residents and staff in the event of a fire. 3 OP19 Primrose Lodge DS0000001700.V306395.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Lodge DS0000001700.V306395.R01.S.doc Version 5.2 Page 21 - 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. 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