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Inspection on 04/08/05 for Primrose Lodge [Bournemouth]

Also see our care home review for Primrose Lodge [Bournemouth] for more information

This inspection was carried out on 4th August 2005.

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

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

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

What the care home does well

Written information about Primrose Lodge is available for prospective residents and their relatives or representatives, to let them know what they can expect from the home and help them decide if Primrose Lodge is right for them. Pre-admission assessments are carried out to ensure that only people whose needs can be met are offered places within the home. Prospective residents are informed of the outcome of these assessments in writing, so they are assured that their care needs can be met. Every resident has a care plan, which sets out in detail the individual`s care needs and the care that staff are expected to give. Care staff are supported in caring for residents by community healthcare professionals, such as GPs, district nurses, chiropodists, opticians etc. Residents feel that they are treated with respect and their right to privacy and dignity is promoted at all times. Open visiting arrangements are in place, so residents are able to maintain contact with visitors whenever they wish. A balanced and varied selection of food is served and residents speak highly of the meals provided. "The chef is excellent." " The chef likes to do that bit extra to make the meals look so appetising." Residents may choose where to eat their meals and the timing is flexible to fit in with visitors, appointments and care needs etc. Residents are confident that complaints would be listened to and dealt with appropriately. No complaints had been received by the home or the Commission since the registration of Primula Care Ltd. in February 2005. The home has a comprehensive Adult Protection policy in place and staff have received training to ensure residents are protected from possible abuse. Considerable investment in the home is resulting in an attractive, wellmaintained and comfortable environment for residents, where Primula Care Ltd. is seeking to provide high standards. The home provides access to attractive communal areas, including gardens. Bedrooms are comfortably furnished and individually personalised by their occupants. A resident commented, " I have everything I need in my room." Primrose Lodge is clean throughout and there are no unpleasant odours. Mrs Mitchell heads a team of enthusiastic staff, most of whom are experienced in caring for people. Residents speak highly of the staff, "The staff are lovely. We are very lucky to have such good people looking after us." "The staff are very kind and patient with me. I am very slow but they never seem to mind."

What has improved since the last inspection?

A new care planning system has been introduced which ensures that staff have all the information they need to meet the needs of residents. A chef has been employed. Residents expressed satisfaction with the food provided. The refurbishment programme has been commenced and the lounge and dining room have been redecorated. A new alarm call system has been installed throughout the home and plans are in hand to replace the boiler and fit new carpets throughout the lounge, hall, stairs and all corridors. New pictures have been purchased depicting local scenes. It is planned to redecorate, recarpet and refurbish all bedrooms and six have been completed so far. The laundry has been fully re-equipped. A number of new and updated policies and procedures have been introduced to offer guidance to staff. New forms have also been introduced, for instance the pre-admission assessment, to ensure that all necessary information is gathered.

What the care home could do better:

There is only limited recorded information available about residents` social, cultural, religious and recreational interests and needs. Without this, it is difficult to ensure that activities provided by the home are tailored to meet individual needs. One or two staff need to complete additional medication training. Supervision is needed to improve some aspects of recording the administration of medicines. Many residents feel there are currently too few activities available and those provided are often of little interest to them. Steps are being taken to find out what residents really want and to provide a better range of activities. A suitable manager must be registered with the Commission as soon as possible.

CARE HOMES FOR OLDER PEOPLE Primrose Lodge 42 St Catherines Road Southbourne Bournemouth Dorset BH6 4AD Lead Inspector Marjorie Richards Announced 4 August 2005 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 D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Primrose Lodge Address 42 St Catherines Road Southbourne Bournemouth Dorset BH6 4AD 01202 429514 01202 429514 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) Primula Care Limited To be appointed. CRH PC - Care Home Only 27 Category(ies) of OP Old age (27) registration, with number of places Primrose Lodge D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. That an application is submitted to the Commission for Social Care Inspection to register a manager within one month of the date of issue of the certificate and that a manager is approved as `fit` within 3 months from the date of issue of the certificate of registration. 2. That all works as recommended by DF&RS and the EHO are completed within two months of the date of issue of the certificate of registration. 3. One named person (as known to CSCI) under the age of 65 may be accommodated to receive care. Date of last inspection First under new ownership 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 (used as singles unless two residents choose to share) 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 lounge overlooks the attractive front garden and the dining room looks out over the rear garden, laid mainly to lawn with mature trees and shrubs and a 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 for the lunchtime meal and a variety of alternatives is available to suit individual taste and preference. Primrose Lodge has recently undergone a change of ownership. Primula Care Ltd took control of the home on 11th February 2005. Primrose Lodge D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6.5 hours on the 4th August 2005. Primrose Lodge underwent a change of ownership when Primula Care Ltd was registered on 11 February 2005. Mr Graham Thomas made himself available throughout the inspection, on behalf of Primula Care Ltd, and this was appreciated. The main purpose of the inspection was to check that the residents living in the home were safe and properly cared for and to check on progress with the registration of a manager and the planned refurbishment of the home. A tour of the premises took place and a variety of 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 ten residents, Mr Thomas, Mrs Mitchell (Manager), the staff on duty and a visitor to the home, in order to get a real feel of what it is like to live at Primrose Lodge. Comment cards were sent out to the home prior to inspection and to date, a total of 15 have been returned, 12 from residents, 2 from relatives and 1 from a healthcare professional. Overall satisfaction was expressed with the standard of care provided at Primrose Lodge. What the service does well: Written information about Primrose Lodge is available for prospective residents and their relatives or representatives, to let them know what they can expect from the home and help them decide if Primrose Lodge is right for them. Pre-admission assessments are carried out to ensure that only people whose needs can be met are offered places within the home. Prospective residents are informed of the outcome of these assessments in writing, so they are assured that their care needs can be met. Every resident has a care plan, which sets out in detail the individuals care needs and the care that staff are expected to give. Care staff are supported in caring for residents by community healthcare professionals, such as GPs, district nurses, chiropodists, opticians etc. Residents feel that they are treated with respect and their right to privacy and dignity is promoted at all times. Open visiting arrangements are in place, so residents are able to maintain contact with visitors whenever they wish. Primrose Lodge D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 6 A balanced and varied selection of food is served and residents speak highly of the meals provided. The chef is excellent. The chef likes to do that bit extra to make the meals look so appetising. Residents may choose where to eat their meals and the timing is flexible to fit in with visitors, appointments and care needs etc. Residents are confident that complaints would be listened to and dealt with appropriately. No complaints had been received by the home or the Commission since the registration of Primula Care Ltd. in February 2005. The home has a comprehensive Adult Protection policy in place and staff have received training to ensure residents are protected from possible abuse. Considerable investment in the home is resulting in an attractive, wellmaintained and comfortable environment for residents, where Primula Care Ltd. is seeking to provide high standards. The home provides access to attractive communal areas, including gardens. Bedrooms are comfortably furnished and individually personalised by their occupants. A resident commented, I have everything I need in my room. Primrose Lodge is clean throughout and there are no unpleasant odours. Mrs Mitchell heads a team of enthusiastic staff, most of whom are experienced in caring for people. Residents speak highly of the staff, The staff are lovely. We are very lucky to have such good people looking after us. The staff are very kind and patient with me. I am very slow but they never seem to mind. What has improved since the last inspection? A new care planning system has been introduced which ensures that staff have all the information they need to meet the needs of residents. A chef has been employed. Residents expressed satisfaction with the food provided. The refurbishment programme has been commenced and the lounge and dining room have been redecorated. A new alarm call system has been installed throughout the home and plans are in hand to replace the boiler and fit new carpets throughout the lounge, hall, stairs and all corridors. New pictures have been purchased depicting local scenes. It is planned to redecorate, recarpet and refurbish all bedrooms and six have been completed so far. The laundry has been fully re-equipped. A number of new and updated policies and procedures have been introduced to offer guidance to staff. New forms have also been introduced, for instance the pre-admission assessment, to ensure that all necessary information is gathered. Primrose Lodge D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 7 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 D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 8 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 D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 9 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 and 3 Information provided about Primrose Lodge and a thorough admissions procedure allows prospective residents to make informed decisions about admission to the home and ensures that only those whose needs can be met are offered places there. The home assures prospective residents in writing that their needs can be met. 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. These documents are included in an information file placed in the entrance hall at Primrose Lodge. This also includes details of the complaints procedure and a Quality Assurance questionnaire. All of these documents and a copy of the homes terms and conditions are provided in every residents bedroom. Individual care records are kept for each resident and three of these were examined. Prior to moving to Primrose Lodge, care needs are fully assessed and a comprehensive form has been developed for this purpose. The manager generally carries out such assessments. A letter of confirmation is then written Primrose Lodge D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 10 to the prospective resident so that they may feel assured their care needs will be met. The information contained in pre-admission assessments and also any assessments supplied by Social Services, is then used to draw up a detailed plan of care. Primrose Lodge D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 11 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 and 10 Primrose Lodge has an excellent care planning system in place, which ensures that staff have the information they need to meet the needs of residents. Health needs are also well met, with evidence of good support from community health professionals. The home has a medication policy describing procedures for giving and recording the administration of medicines. Some medicines have been properly recorded indicating that occasionally procedures are not followed and some lack of awareness when signing medication as given, which potentially puts residents at risk. Residents are treated with respect and their privacy and dignity is promoted at all times. EVIDENCE: All three of the care plans examined are clearly set out, detailing the particular health and personal care needs of each resident, the aims and objectives and the staff assistance necessary to ensure these are met. Information about social care needs however, is more limited. Primrose Lodge D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 12 Evidence was seen to show that care plans are regularly reviewed and updated where necessary. Daily care notes support and evidence the delivery of care to residents. These are well detailed and give a good picture of the care delivered to residents, visits by community health professionals and relatives etc. Records demonstrate that residents have access to GPs, district nurses, chiropodists, etc and attend hospital appointments as necessary. This was confirmed by residents and observed during the inspection. Risk assessments are in place and appropriate steps are taken to ensure any risks identified are minimised. The Commission For Social Care Inspection Pharmacist Inspector inspected the arrangements for dealing with medication at Primrose Lodge. The home has a medication policy describing procedures for giving and recording the administration of medicines. Some handwritten entries on the Medicine Administration Record were countersigned but others were not. Records of administration of one medicine for each of two residents were confusing due to duplication of the records. Medicines given to another resident on the day of the inspection were not signed as given. An Immediate Requirement Notice was issued concerning these issues. Records of an audit of medication the day before the inspection were seen but this had not identified the duplicated records. From the training records examined, 1 or 2 staff who give medicines have not had any additional medication training. Staff were observed throughout the inspection to be treating residents with courtesy, patience, kindness and respect. Staff always knocked at bedroom doors and toileting activities were carried out discreetly. Residents commented, The staff are very good here, polite and helpful. They show respect for older people. The staff have always treated me well. All residents were well-presented and wearing jewellery, spectacles etc, where appropriate. Apart from two residents who have expressed a wish to share, all residents occupy their own bedrooms, thereby offering an opportunity to be on their own if they wish, or allowing privacy for any visitors or personal care needs. Residents commented, I can go to my room whenever I wish. I can spend my time wherever I want to. Sometimes I enjoy being with others, but much of the time I prefer to be in my room. It is my choice. Primrose Lodge D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 13 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 and 15 The range of activities available to residents is currently very limited, as is the information recorded about individual residents social, cultural, religious and recreational needs, making it difficult to assess if their needs and expectations are fully met. Open visiting arrangements are in place, so residents are able to maintain contact with visitors as they wish. Primrose Lodge serves a balanced and varied selection of food that meets residents’ tastes and special dietary needs within a variety of pleasant surroundings. EVIDENCE: Of the 12 comment cards received from residents, in response to the question Does the home provide suitable activities? 4 residents said Yes, 4 said No and 4 said Sometimes. Residents commented that the home had provided few meaningful activities for some time. There is nothing much to do here. None of the activities interest me at all. I can take it or leave it, but I mostly leave it. We always have the same old thing, over and over again and it doesnt interest me. Primrose Lodge D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 14 Mr Thomas is aware that Primrose Lodge is not currently meeting many residents expectations and preferences in terms of recreational and social needs etc and is actively planning to seek their views for improvements. Suggestions so far include quizzes, manicures and bingo. Regular entertainment is arranged but residents commented that this was Always the same people. Gentle movement to music sessions are arranged on a weekly basis. A group of residents enjoyed playing bingo in the lounge during the afternoon of the inspection. At present, care plans contain only limited information about residents background, social history, previous hobbies and interests etc. Mrs Mitchell is looking to prepare life histories, which will help to ensure that the activities on offer at Primrose Lodge will be meeting the individual needs, preferences and expectations of residents. Arrangements are made for clergy to visit individual residents upon request. Residents confirm that visiting times at Primrose Lodge are unrestricted and a visitor commented, I am always well received, whatever time of day I arrive. Residents records and the visitors book demonstrate contact with family and friends as well as visits by professionals. Several residents are able to go out of the home alone and others with their families/friends or with staff. Nine residents have their own telephones, so can easily maintain family and community links and a coin operated telephone is also available. Lunch on the day of inspection was roast lamb, with roast and boiled potatoes, cauliflower and runner beans OR corned beef hash. This was followed by pears with chocolate sauce, ice cream or cheese and biscuits. The chef has information available about individual likes/dislikes and alternatives are always provided to suit individual taste and preference. Residents may choose to eat their meals in the lounge, dining room or in their bedrooms. In good weather, coffee and tea are sometimes served in the garden. Mealtimes can be flexible to fit in with care needs, appointments etc. The menu shows that residents enjoy a healthy, well-balanced diet. Fresh fruit and vegetables are used wherever possible. Specialist diets are catered for. Feedback from residents comment cards in response to the question, Do you like the food? produced the following responses: - 7 residents said Yes, 1 said No and 4 said Sometimes. During the inspection residents commented, The standard of food has greatly improved in the last few months, since the new chef came. I have never had a bad meal here yet. The chef is excellent. The chef likes to do that bit extra to make the meals look so appetising. The lamb we had today was the best Ive ever tasted. Primrose Lodge D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 15 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 and 18 A system is in place for dealing with any complaints. Residents are confident complaints would be listened to and dealt with appropriately. The home has a comprehensive Adult Protection policy in place to ensure residents 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 entrance hall. No complaints have been received by the home or the Commission since Primula Care Ltd. were registered in February 2005. Contact with residents and visitors demonstrated they would feel able to voice a complaint and felt that their concerns would be taken seriously, and acted upon. Comments included: I have no complaints about this place, none at all.” You can always talk to the boss if you are worried about anything.” The home has a comprehensive Adult Protection policy in place to protect service users from possible abuse. This makes reference to the Department of Health No Secrets document, which is also available to staff. 12 staff have now received Adult Protection training and further training is booked for the remaining staff. Staff later confirmed they had found the Adult Protection training helpful in identifying the different forms of abuse and how to deal with any suspicion of abuse, to ensure residents are safe within the home. Primrose Lodge D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 16 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, 20, 24 and 26 Considerable investment in the upkeep and refurbishment of the home is resulting in an attractive, well-maintained, comfortable and safe environment for residents, where standards are constantly improving. The home provides access to attractive communal areas, including gardens. Bedrooms are comfortably furnished and individually personalised to suit their occupants. Primrose Lodge is clean with no unpleasant smells, making daily life more pleasant for all in the home. EVIDENCE: Inspection of the premises demonstrated that routine maintenance is being carried out and a programme of refurbishment has commenced. The dining room and lounge have been redecorated. A new alarm call system has been installed throughout the home and all response times are logged so that the manager can check that calls are answered properly. Plans are in hand to replace the boiler and fit new carpets throughout the lounge, hall, stairs and Primrose Lodge D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 17 corridors. New pictures, depicting local scenes, have been also been purchased to improve the appearance of corridors. Hot water temperatures at baths were tested and found to be close to the recommended temperature of 43C, to prevent any risk of scalding. The fire records show appropriate checks being carried out on the fire warning system, emergency lighting and fire fighting equipment and staff take part in fire training and drills so that they are fully aware of what to do in the event of fire. Portable Appliance Testing is carried out to ensure that electrical appliances are operating safely. Primrose Lodge has a lounge and separate dining room. These adjoining rooms are attractively presented. Furnishings are good quality and domestic in character. The garden areas are, in the main, accessible to wheelchair users. However, access from the front door can be difficult as there is a ridge and small step to negotiate. Mr Thomas intends to develop better access as part of the planned improvements for the home. Garden seating is available to service users wishing to sit outside and patio tables, chairs and umbrellas are also available during the warmer weather. A rail has been fitted around the patio area outside the dining room to improve resident safety. A tour of the building confirms that residents bedrooms are comfortably furnished and personalised to varying degrees. Residents commented, “I have a lovely room, I am very pleased with it.” I have everything I need in my room. Six bedrooms have been redecorated and completely refurbished. It is intended that all bedrooms will be redecorated and provided with new carpets, curtains, bed, bedding and high-quality furniture over a period of time. The home is clean and there are no unpleasant smells, making life within the home more pleasurable. The laundry has recently been equipped with new washing machines and a tumble dryer. Suitable procedures are in place for the disposal of clinical waste. Primrose Lodge D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 18 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 The home is well staffed and staff morale is high, resulting in an enthusiastic workforce that works positively with residents to enhance their lifestyles. 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 needs of residents. At the time 8 a.m. to 2 2 p.m. to 8 8 p.m. to 8 of inspection, the following care staff were on duty: p.m. - 3 care staff. p.m. - 3 care staff. a.m. - 2 care staff (wakeful). The home employs a total of 18 staff, including a chef, domestic and maintenance staff. An equal opportunities policy underpins the employment practice of the home. Staff and residents spoken with felt that the staffing levels had improved in recent months and were now generally satisfactory. Relationships between staff and residents were directly and indirectly observed throughout the course of the inspection. They were friendly and relaxed, whilst remaining professional. Staff appeared enthusiastic in their work, with one member of staff commenting, I actually enjoy coming to work now. One resident with short-term memory loss was observed during the afternoon to be repeatedly returning to the kitchen asking for cups of tea or biscuits. Primrose Lodge D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 19 The member of staff, who was clearing up after lunch, demonstrated endless patience when she continually broke off from what she was doing to talk happily with the resident and provide cups of tea and the occasional biscuit. Residents commented, The staff are lovely. We are very lucky to have such good people looking after us. The staff are very kind and patient with me. I am very slow but they never seem to mind. I dont like to bother the staff because I know they are busy but they always say it is no bother, it is what they are there for. They are always there when you need them.” Primrose Lodge D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 20 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) 31, 32 and 35 Mrs Mitchell leads by example to ensure that residents receive a consistently high standard of care. She is supported well by senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. Residents are assured of sound management of their financial interests. EVIDENCE: One of the conditions of registration for Primula Care Ltd. is that a manager is registered with the Commission for Social Care Inspection and this has not yet been met. Mrs Mitchell has recently been appointed to the post of manager at Primrose Lodge, having worked previously as assistant manager. She is currently in the process of submitting her application for registration as manager with the Commission. Primrose Lodge D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 21 Mrs Mitchell has experience in caring for older persons and is commencing her a National Vocational Qualification (NVQ) level 4 in care and management. The home has an open, relaxed atmosphere, which is beneficial to residents, staff and visitors. A resident commented, This place suits me very well. Discussions with staff show that they are clear about their roles and responsibilities within the home and feel they are an important part of the team. They speak positively about Mrs Mitchell and her management approach. There have been a lot of changes recently and Mrs Mitchell is very supportive. You can always talk to her, she is very understanding. If I had a problem, I know I could talk to Mrs Mitchell and she would listen. Because of recent changes in the management team, many residents appear unaware that Mrs Mitchell has now been appointed manager of the home. This will no doubt be addressed in the coming weeks. A number of new and updated policies and procedures have been introduced to offer guidance to staff. Mr Thomas says that, in order to protect residents, it is the policy of the home not to have any involvement in their personal finances. Therefore, all residents who are unable or do not wish to handle their own affairs, have a relative or other representative to deal with their finances etc. The home never handles residents monies, but pays for services such as chiropody and hairdressing and this amount is then invoiced to residents, relatives or representatives for payment each month. Information about advocacy services solicitors and seeking financial advice is available to residents within the home and policies are in place precluding staff acceptance of gifts or involvement in residents wills. Primrose Lodge D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 22 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 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 3 x x 3 x x x Primrose Lodge D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 23 N/A 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(1) and 15(2) Requirement All aspects of each resident s health and welfare needs, including social care needs, must be recorded and regularly reviewed. Staff must accurately record the administration of medicines at the time they are given. All staff who administer medicines must have training on the administration of medicines, how they are used and how to recognise and deal with problems in use. The registered person must consult residents about their interests and provide a suitable programme of activities. Timescale for action 30/11/05 2. 9 13(2) Immediate 3. 9 13(2) 30/11/05 4. 12 16(2) (m) and (n) 30/11/05 5. 31 8(1) An Application must be 31/8/05 submitted to the Commission for Social Care Inspection to register a suitable person as manager. Primrose Lodge D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 24 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 9 Good Practice Recommendations When staff handwrite details of prescribed medicines on to the medicine chart a second competent person should check and sign to confirm that all the details are correct. Primrose Lodge D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Unit 4 New Fields Business Park Stinsford Road Poole Dorset BH17 0NF 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 D55 S63469 Primrose Lodge V235214 040805 Stage 4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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