Inspection on 11/01/08 for Primrose Lodge [Bournemouth]

This inspection was carried out on 11th January 2008.

CSCI found this care home to be providing an Good service.

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 [Bournemouth] 28/01/09

Primrose Lodge [Bournemouth] 01/09/06

Primrose Lodge [Bournemouth] 09/11/05

Primrose Lodge [Bournemouth] 04/08/05

Primrose Lodge [Bournemouth] 25/01/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Primrose Lodge 42 St Catherines Road Southbourne Bournemouth Dorset BH6 4AD Lead Inspector Marjorie Richards Key Unannounced Inspection 9:50 11th January 2008 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 DS0000063469.V344167.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 DS0000063469.V344167.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Primrose Lodge Address 42 St Catherines Road Southbourne Bournemouth Dorset BH6 4AD 01202 429514 F/P01202 429514 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) Primula Care Limited Mrs Deborah Louise Mitchell Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named person (as known to CSCI) under the age of 65 may be accommodated to receive care. Within the total of 27 places, two service users may be accommodated within Primrose Lodge over the age of 50. 1st September 2006 Date of last inspection Brief Description of the Service: Primrose Lodge is a large, converted Edwardian property, situated in a residential area of Southbourne in Bournemouth. Local shops are within level walking distance and cliff-top walks about half a mile from the home. The main shopping area of Southbourne with all its amenities, is less than one mile away. Bus services are available close by to all parts of Bournemouth, Christchurch and beyond. The property is approached via a driveway with a parking area for visitors. Additional parking is available on nearby roads. Primrose Lodge is registered to accommodate up to 27 older persons. The accommodation is arranged over three floors, with a two-person passenger lift to aid access between the floors. There are four double bedrooms and nineteen single rooms. All bedrooms, with the exception of one, have en-suite facilities. The lounge and separate dining room are situated on the ground floor. The home has an attractive front garden and a rear garden that is laid mainly to lawn with mature trees and shrubs and a spacious paved patio area. Twenty-four hour care is provided. Laundering of personal clothing etc is carried out on the premises. All meals are prepared and cooked within the home. A choice of menu is offered and a variety of alternatives are available to suit individual taste and preference. Activities are available to provide some stimulation and interest for residents. The fees for the home, as confirmed to the Commission for Social Care Inspection (CSCI) at the time of inspection, range from £390 - £550 per week. Additional charges include hairdressing, chiropody, dry cleaning, toiletries and newspapers. Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 5 The Office of Fair Trading has published a report highlighting important issues for many older people when choosing a care home, e.g., contracts and information about fees and services. Further information can be obtained from the following website: http:/www.csci.org.uk/about_csci/press_releases/better_advice_for_people choosing a care home. aspx Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This unannounced inspection took place over 8.75 hours on the 11th January 2008. The main purpose of this inspection was to review the key National Minimum Standards, check that the residents living in the home were safe and properly cared for and to look at progress in meeting the two requirements from the previous inspection. The Annual Quality Assurance Assessment (AQAA) form had been completed by Mrs Mitchell and provided to the Commission for Social Care Inspection in advance of the inspection. Recent legislation has made it a legal requirement for all registered services for adults to complete an AQAA every year. The completed assessment is one of the ways in which we assess how well the service is delivering good outcomes for the people using it. On the day of inspection, 22 residents were accommodated. A tour of the premises took place and records and related documentation were examined, including the care records for three residents. Time was spent observing the interaction between residents and staff, as well as talking with eight residents. The daily routine was also observed during the inspection. Discussion took place with Mrs Mitchell, the registered manager and with members of staff on duty. Mr Graham Thomas (on behalf of Primula Care Ltd) made himself available for most of the inspection and this was appreciated. For the purposes of this report, people who live at Primrose Lodge are referred to as residents as this is the term used within the care home. The Inspector was made to feel very welcome in the home throughout the visit. What the service does well: The Statement of Purpose and Service User Guide contain detailed information about the home and its facilities, giving a good indication of what a resident can expect from the home. Copies are provided in every residents bedroom. They are also included in an Information File placed in the entrance hall at Primrose Lodge, where a copy of the current inspection report is available. Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 7 Mrs Mitchell has also produced an additional guide for those residents coming to the home for respite or short–term care. Primrose Lodge provides a clean and well-maintained home where the personal, health and social care needs of residents are met. Care planning documentation is comprehensive. It includes questions about how the resident likes to be addressed, their wishes regarding the gender of staff caring for them, preferred form of address, religion, ethnicity and spoken language. The residents describe the home as a very relaxed and friendly place to live where the staff are helpful and supportive. The staff treat residents with respect and provide encouragement for them to pursue their own lifestyles, wherever possible, and to make choices about their daily lives. Observation and discussion confirms that staff respect the individual preferences and routines of residents. A resident commented, We can get up when we like. I like to get up about 9 a.m. and I prefer to be in bed by 8 p.m. I think I am well looked after and I wouldnt change anything. Activities are available for those residents who wish to participate and the manager is seeking to further improve these. Residents are supported to maintain contact with family and friends, enabling those living in the home to continue to enjoy relationships that are meaningful to them. Residents say, My visitors come regularly and are always made to feel welcome. This home is friendly and relaxed and visitors can come at any time which suits me. Residents are able to choose where to take their meals within the home. All residents spoken with were very positive about the quality of the meals provided. I think we are lucky to have such a good cook. In some places the food is not very good, but I enjoy my meals here. We have a good choice and there is always something cooked if you want it. I’ve been in places where the meals are not half as good as they are here. Primrose Lodge is clean and free from unpleasant odours. Residents commented, “This place is always kept spic and span.” “The staff keep everything clean and tidy.” Residents also express satisfaction with the laundry arrangements. Residents and staff agree that Primrose Lodge is a good place in which to live and work. For example, residents say, The staff are lovely. Everyone is very friendly, which I like.” Staff say: “Primrose Lodge is a good place to work, everyone is very friendly and supportive.” “I enjoy my work very much. It is also a pleasure to come to work at Primrose Lodge.” Quality Assurance questionnaires are sent to residents, staff, relatives and other visitors to the home to obtain their views. In order to protect residents, the home prefers to have no involvement in personal finances. Therefore, all residents who are unable or have no wish to Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 8 handle their own affairs have a relative or other representative to deal with their finances. Measures are in place to promote the health and safety of residents, e.g. equipment, such as the lift, alarm call system, hoists and fire precautions etc are regularly serviced and maintained. 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. The summary of this inspection report can be made available in other formats on request. Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 9 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 DS0000063469.V344167.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Standard 6 is not applicable at Primrose Lodge. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to Primrose Lodge. Information provided about Primrose Lodge allows prospective residents to make informed decisions about admission to the home. Such admissions only take place when the home is confident that they are able to meet the assessed needs of the prospective resident. EVIDENCE: The Statement of Purpose and Service User Guide contain all of the information required about the home and its facilities. The Service User Guide gives a good indication of what a resident can expect from the home and includes details of the complaints procedure and a Quality Assurance questionnaire. All of these documents are provided in every residents bedroom. They are also included in an Information File placed in the entrance hall at Primrose Lodge, where a copy of the current inspection report is available. Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 11 This file includes photographs and further information about the services available in the home, such as hairdressing, chiropody, opticians and dentists. Information is also provided about menus, advocacy services for those requiring independent advice and support and the results of Quality Assurance surveys in the home, with analysis and an action plan. All of the information is provided in an easy to read format and in large print. Mrs Mitchell has also produced an additional guide for those residents coming to the home for respite or short–term care. Individual care records are kept for each resident and two of these were examined for recently admitted residents. They showed that, prior to moving to the home, care needs had been assessed by Mrs Mitchell. Mrs Mitchell says that she always visits prospective residents or invites them to the home, prior to making a decision as to whether Primrose Lodge is suitable to meet their needs. An assessment form has been developed for this purpose. This is in addition to information supplied by any funding authorities. A letter of confirmation is then written to the prospective resident so that they may feel assured their care needs can be met. Residents say that they (or their relatives) had been offered the opportunity to visit the home before making the decision to move there. Staff also confirm that they were aware of the resident’s needs at the time of their admission. Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to Primrose Lodge. Residents are treated with respect and their personal care needs are met, with the home ensuring they have access to a range of healthcare services to meet all assessed needs. EVIDENCE: Following admission to the home, further assessments are carried out and a care plan is drawn up, identifying the needs of each resident and how staff are to meet these needs. Care planning documentation is comprehensive. It includes questions about how the resident likes to be addressed, their wishes regarding the gender of staff caring for them, preferred form of address, religion, ethnicity and spoken language. Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 13 Care records for three residents were examined. Observation and discussion with staff and residents confirmed that care plans reflect the actual care provided. Mrs Mitchell says that, wherever possible, initial care plans and any subsequent changes are agreed by the resident themselves, or, if this is not possible, by a relative or representative. This was evidenced on the care plans examined. Care plans also demonstrate that regular reviews are taking place and care plans are updated as necessary to reflect any changing needs. Good daily records are written by both day and night staff to evidence the care being provided. These also show that residents have access to General Practitioners, district nurses, dentists, chiropodists, physiotherapists, opticians etc and attend appointments as necessary. This was later confirmed in discussion with residents and staff and care staff demonstrated a good knowledge of residents’ individual care needs. The home has systems in place for managing medicines. Staff dealing with medication undertake a course of related training. Medicines are stored securely, to ensure the protection of residents. A Monitored Dosage System is in use. Samples of the cassettes were checked with the Medicine Administration Records (MAR) charts, to ensure that medicines had been administered correctly, as prescribed and properly recorded. Discussion took place with Mrs Mitchell regarding the method of administration of medicines for one resident and she was advised to contact the General Practitioner for confirmation. The homes Statement of Purpose says that residents will not be discriminated against or receive less favourable consideration on the grounds of race, gender, sexual orientation, marital status, age, disability, language ability, literacy or religion. Staff induction training includes information about respecting the individuality, privacy and dignity of residents. This was confirmed when speaking with staff. Staff were seen to knock at bedroom doors and to offer personal care discreetly. They interact with residents in a friendly, relaxed yet respectful manner. It was clear from observation and the time spent with residents that they feel comfortable and at ease with staff. Staff were seen throughout the inspection to be treating service users with courtesy and kindness. Only those residents who have expressed a wish to share, occupy the double bedrooms. (These rooms are currently being used for single occupancy.) Residents confirm that they are able to go to their own bedrooms whenever they wish, thereby offering an opportunity to be on their own or allowing privacy for any visitors or personal care needs. Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 14 Residents commented, The staff are very good I think. They are always pleasant and polite. I like to spend time in my room. I can go to the lounge if I wish to, but why would I want to do that when I have such a lovely room. I like the fact that you can share a laugh and a joke with some of the girls (staff) if you want to. Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to Primrose Lodge. The home is flexible in its approach to the provision of activities and meals, enabling residents to retain control over their lives wherever possible. EVIDENCE: Wherever possible, staff try to find out as much information as possible about the background of residents. Where residents are unable to provide such details, these are sought from relatives, friends or representatives. Social histories have been completed for the majority of residents and it is hoped that these will now be used to inform the home about hobbies and interests and assist in the planning of activities. Since the last inspection, the activities organiser has left and care staff are currently providing activities. The planned activities for the week are displayed on a noticeboard in the dining room. These include gentle exercise to music, skittles, bingo, quizzes, manicures, singalongs and film afternoons. Residents participated in a quiz in the lounge during the afternoon of the inspection. For those residents unable to participate in group activities, limited one-to-one support is provided. Mrs Mitchell is hoping to improve on this and Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 16 is looking to recruit another activities organiser, thus ensuring that each resident receives sufficient opportunities for social activity and stimulation on a regular basis. She has spoken with residents about the activities on offer and some have said they would like to go on a group outing. Mrs Mitchell is currently looking at ways of arranging this. Mrs Mitchell says that she and her staff take a flexible approach to the running of the home to fit in with residents needs and wishes. Residents are assisted to attend church if required and arrangements are made for clergy to visit individual residents upon request. Some residents enjoy watching the church services on television as well as Songs of Praise on Sundays. Residents and staff confirm that visiting times at Primrose Lodge are unrestricted and residents say that their visitors are made welcome and served with refreshments. Residents records and the visitors book demonstrate contact with family and friends as well as visits by professionals. A telephone is provided for the use of residents and they may also arrange to have their own telephones installed, to maintain family and community links. Residents commented, My visitors come regularly and are always made to feel welcome. This home is friendly and relaxed and visitors can come at any time which suits me. Residents are encouraged to choose their own lifestyle within the home and make choices wherever possible. These include choosing when to get up or go to bed, what to wear, what to eat or drink and freedom to come and go as they please. They are able to bring their own possessions into the home to personalise their bedrooms. Observation and discussion confirms that staff respect the individual preferences and routines of residents. A resident commented, We can get up when we like. I like to get up about 9 a.m. and I prefer to be in bed by 8 p.m. I think I am well looked after and I wouldnt change anything. The daily menu is displayed on a blackboard in the dining room. Lunch on the day of inspection was baked or fried fish, or vegetable pie, with chipped or mashed potatoes, baked beans, peas or tomatoes. This was followed by a variety of ice creams, including Vienetta. A wide range of alternatives is always available, such as omelettes, jacket potatoes with assorted fillings, a variety of soups and salads to suit individual preference or taste. The menu shows that residents receive a varied and nutritious diet. A choice of apple, orange or cranberry juice is offered with lunch and two bowls of fresh fruit are available in the dining room, for residents to help themselves whenever they wish. The home has a good supply of foodstocks, all appropriately stored. Meals are seen as social occasions and the lunchtime meal took place in a relaxed, unhurried and congenial atmosphere with discreet staff assistance provided wherever necessary. Residents may choose where in the home they Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 17 eat their meals. Residents were observed making choices about what they wished to eat during the day. Residents commented, I think the food here is very good on the whole. I’ve been in places where the meals are not half as good as they are here. I always enjoy icecream. We have a good variety here. I think we are lucky to have such a good cook. In some places the food is not very good, but I enjoy my meals here. We have a good choice and there is always something cooked if you want it. Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to Primrose Lodge. The systems in place provide residents with the confidence that their complaints will be listened to and acted upon and they are protected from possible abuse. EVIDENCE: The home has a complaints policy and procedure that is included in the Service User Guide provided to all residents in their bedrooms. A copy of the complaints policy is also available to visitors in the Information File in the entrance hall. The complaints record shows that three complaints have been received since the last inspection. One is currently being investigated. The second complaint was partially substantiated and appropriate action taken. The third complaint was found to be unsubstantiated. Discussions with residents demonstrate that they would feel able to voice a complaint if necessary and their concerns would be taken seriously, and acted upon. Comments include: “I have no complaints about anything. I am very happy here.” Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 19 I have no complaints. If I did, I would speak to Debbie. (Manager) You can always talk to Debbie, I get on with her very well. If you have a problem, she will sort it out.” The home has a comprehensive Adult Protection policy in place to protect residents from possible abuse. This makes reference to the multi agency No Secrets document, which is also available to advise staff. An error was noted in the contact details for the local social services, but Mr Thomas undertook to correct this straight away. Not all staff have received Adult Protection training, to ensure a proper response to any suspicion or allegation of abuse, but further training is booked later in January 2008. Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to Primrose Lodge. Environmental standards are good, providing residents with comfortable, clean and well-maintained surroundings in which to live. EVIDENCE: A tour of the building, confirms that improvements are continuing to take place, as part of the general refurbishment of the home. All except five bedrooms have now been completely refurbished with new carpets, curtains, bed, bedding and high-quality furniture. A number of replacement windows have also been fitted. A new television has been purchased for the lounge and an electric organ provided for anyone to play. New flat screen televisions have been provided in most bedrooms. Several residents commented that this had made viewing television easier for them as the picture was much more clear. Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 21 Records show that continual work is carried out to keep the home and garden in good condition, with a member of staff employed to carry out maintenance tasks. Care staff confirm that prompt attention is always paid to any defects. The laundry is equipped with two washing machines and two tumble dryers. Residents expressed general satisfaction with the laundry service provided in the home. An infection control policy is in place. Training records show that nearly all staff have completed training in infection control and the staff on duty confirmed this. Suitable procedures are in place for the disposal of clinical waste. Residents commented, “This place is always kept spic and span.” “The staff keep everything clean and tidy.” However, one room has an unpleasant odour. Mrs Mitchell is aware of this and has tried a variety of means to deal with the problem, with only limited success. She is currently taking advice regarding more appropriate action to rectify the situation. Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to Primrose Lodge. Primrose Lodge has systems in place to ensure that staff are only recruited after a rigorous screening process and then receive suitable training to make sure they are able to meet the needs of the residents. EVIDENCE: Examination of the staff rota and observation throughout the inspection demonstrated there was a sufficient number and skill mix of staff to meet the current needs of residents. At the time of inspection, the following care staff were on duty: 8 a.m. to 8 p.m. - 3 care staff 8 p.m. to 8 a.m. - 2 care staff (1 wakeful and 1 sleeping, on call). Primrose Lodge currently employs a total of sixteen staff, including a cook, domestic and maintenance staff. This team of care and support staff are working positively with residents to ensure their needs can be met. Relationships between staff and residents were directly and indirectly observed throughout the course of the inspection. Staff were seen to be responding to needs appropriately and undertaking good care practice, demonstrating a friendly, gentle approach when dealing with residents. Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 23 Residents commented, The staff are good here on the whole. Most are very helpful and happy to do that bit more to help you if you need it. The staff are lovely. Everyone is very friendly, which I like.” The girls are very good. They have all looked after me so well.” The home employs a total of twelve care staff and has now almost achieved the recommended target of at least 50 trained members of care staff with National Vocational Qualification (NVQ) level 2, to ensure residents at Primrose Lodge are in safe hands. Several staff are currently undertaking NVQ training. The three staff files examined demonstrate that the home is operating a thorough recruitment procedure, to ensure the protection of residents. All necessary documentation is in place, including: • Application form with employment history • Two written references • Enhanced Criminal Records Bureau disclosure • Protection Of Vulnerable Adults check • Proof of identity documentation A satisfactory enhanced Criminal Records Bureau check and Protection of Vulnerable Adults (POVA) check had been received prior to the member of staff commencing employment. Staff files also contain copies of training certificates and formal supervision records. An equal opportunities policy underpins the employment practice of the home. The home provides staff training as a means of improving the standard of care and ensuring residents safety. Training records and discussions with staff confirm that training courses have included moving and handling, first aid, basic food hygiene, health and safety, infection control and the administration of medicines. Further training is being planned, including dementia and challenging behaviour. All new staff receive induction training. This includes a short introduction to the home followed by a more comprehensive induction, which is based on the Skills for Care Common Induction Standards. Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to Primrose Lodge. The management arrangements at Primrose Lodge and the quality assurance systems in place, ensure that the residents live in a home that is well managed and the service provided meets their needs. EVIDENCE: Mrs Mitchell is the registered manager at Primrose Lodge, having worked previously as assistant manager. She has experience in caring for older persons and has now achieved her National Vocational Qualification (NVQ) level 4 in care and the Registered Managers Award. Mrs Mitchell feels that this has helped her to ensure good management practice within the home. Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 25 Primrose Lodge provides a supportive, caring and relaxed environment where residents say they feel comfortable and secure. Mrs Mitchell describes herself as a very “hands-on” manager and feels it is important to remain open and accessible to residents, visitors and staff. This was demonstrated throughout the inspection. Mrs Mitchell clearly has a good relationship with residents and staff. She confirms that she feels well supported by the registered provider, Primula Care Ltd. Records show that care staff are receiving formal supervision at least six times a year, as a means of ensuring good practice, emphasising the philosophy of care within the home and looking at individual career development needs etc. Residents speak highly of the manager: “I find Debbie (manager) to be very helpful and very kind. You can always talk to her.” “The lady in charge will come round and see us for a chat.” “I find Debbie is someone you can rely on.” Staff commented: “Primrose Lodge is a good place to work, everyone is very friendly and supportive.” “Debbie is not afraid to roll up her sleeves and get stuck in when necessary. I respect her for that. She is not the sort of manager who sits in an office all day.” “I enjoy my work very much. It is also a pleasure to come to work at Primrose Lodge.” Quality Assurance questionnaires are sent to residents, staff, relatives and other visitors to the home to obtain their views. Feedback from these is available in the Information File in the entrance hall. Regular audits also take place within the home and policies and procedures are regularly reviewed to ensure best practice. Staff meetings are held every two to three months and provide opportunities for staff to express their views and ideas. Staff appraisals are carried out annually to ensure they are fulfilling their role satisfactorily and meeting the needs of residents. Resident meetings take place approximately 6 monthly and relatives are invited to attend. In order to protect residents, the home prefers to have no involvement in personal finances. Therefore, all residents who are unable or have no wish to handle their own affairs have a relative or other representative to deal with their finances. At present, the home pays for services such as chiropody and hairdressing and keeps a record of what is owed. This amount is then invoiced to relatives or representatives for payment. Information about advocacy services is available to residents and their relatives in the Information File within the home, should they need independent advice or support. From touring the premises, looking at records and discussions with staff and residents, it is evident that measures are in place to promote the health and Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 26 safety of residents, e.g. equipment, such as the lift, alarm call system, hoists etc are regularly serviced and maintained. Mr Thomas agreed to forward a copy of the current electrical certificate to the Commission. All substances that could be potentially hazardous to health are handled and stored safely and restrictors are fitted to windows. Work to fit guards to radiators and pipework to protect residents from potentially hot surfaces and ensure their safety has now almost been completed. It was noted that some of the radiator guards in place have not yet been securely fixed to the wall to prevent any possibility of them toppling over. This was discussed with Mr Thomas, who promised immediate action to ensure the safety of radiator guards. A Risk Assessment file is maintained and regular reviews take place each month, to ensure the safety of the building, equipment etc. Safety data and product information is held for materials in use in the home. Examination of the fire records shows that appropriate procedures are in place to ensure the safety of residents and staff. Regular maintenance of the fire warning system, emergency lighting and fire fighting equipment is taking place. Routine checks are carried out at appropriate intervals and staff confirm this. Staff fire training and fire drills are arranged so that staff are fully aware of the action to take in the event of a fire. A fire risk assessment is in place. Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 27 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 4 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 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 DS0000063469.V344167.R01.S.doc Version 5.2 Page 28 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 OP26 Regulation 16(2)(k) Requirement Timescale for action 29/02/08 2. OP18 13(6) The registered persons must take action to eradicate the unpleasant odour in one bedroom. The registered persons must 29/02/08 ensure that all staff receive Adult Protection training. 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 OP38 Good Practice Recommendations It is recommended that all radiator covers be checked to ensure they are securely fitted and present no risk to residents. Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Primrose Lodge DS0000063469.V344167.R01.S.doc Version 5.2 Page 30 - 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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