Inspection on 09/11/05 for Primrose Lodge [Bournemouth]

This inspection was carried out on 9th November 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Primrose Lodge [Bournemouth] 28/01/09

Primrose Lodge [Bournemouth] 11/01/08

Primrose Lodge [Bournemouth] 01/09/06

Primrose Lodge [Bournemouth] 04/08/05

Primrose Lodge [Bournemouth] 25/01/05

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Fairfields Country Rest Home

Poldhu

Queensmount

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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 Unannounced Inspection 9th November 2005 10:15 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.V263151.R01.S.doc Version 5.0 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.V263151.R01.S.doc Version 5.0 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 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 Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 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. 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. One named person (as known to CSCI) under the age of 65 may be accommodated to receive care. 4th August 2005 2. 3. 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 (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 are available to suit individual taste and preference. Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 4.75 hours on the 9th November 2005. Primrose Lodge underwent a change of ownership when Primula Care Ltd was registered on 11 February 2005. Mr Graham Thomas made himself available later in the inspection, on behalf of Primula Care Ltd, and this was appreciated. The main purpose of the inspection was to see the residents living in the home were safe and properly cared for and to check on progress in meeting the requirements from the last inspection. 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 eight residents, Mrs Mitchell (Manager), Mr Thomas and members of staff on duty, in order to get a real feel of what it is like to live at Primrose Lodge. What the service does well: Prospective residents and their relatives are encouraged to visit Primrose Lodge prior to admission. This gives them an opportunity to look round the home, assess the facilities and asked any questions. A trial period of four weeks is available. A flexible approach is taken to the running of Primrose Lodge. Residents are encouraged to choose their own lifestyle within the home and make choices wherever possible. Individual preferences and routines are respected. Residents live in an attractive, well-maintained and comfortable environment. Equipment is available to assist residents in maximising their independence. Bedrooms are comfortably furnished and personalised by their occupants. Residents commented, I have a lovely room, I am very pleased with it. I have everything I need in my room. The home has a detailed recruitment policy, which makes sure that appropriate checks are carried out prior to employment commencing, for the protection of residents. Residents speak highly of the staff at Primrose Lodge. The following comments are typical: - The staff here are very good, they will get you anything you need. Most of the girls (staff) here know me very well and are very good to me. The home is well managed, to ensure that residents received a consistently high standard of care. The home regularly reviews its performance and Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 Page 6 actively seeks the views of residents, staff and relatives through discussion and the use of questionnaires, to ensure the home is run in the best interests of those living there. What has improved since the last inspection? What they could do better: Minor amendments are needed to the terms and conditions of residence to ensure it provides accurate information. Many residents commented favourably about the food but some were not completely satisfied. Some said they were not always sure what was on the menu each day and others said they were not consulted about what they would like to eat for lunch. Primrose Lodge does not currently achieve the minimum ratio of 50 per cent trained members of care staff at NVQ level 2, to help ensure residents are in safe hands. However, plans are in hand for seven staff to commence training early in 2006. Records show that, over a period of time, staff have undertaken a variety of training to improve their knowledge and care skills. However, some of this training, e.g. first aid, is in need of updating and it is necessary to ensure that all staff, including those more recently employed, have received training in moving and handling, infection control, first aid etc. Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 Page 7 A formal staff supervision system is now in place, but this is not being implemented at the recommended intervals. A number of measures are in place throughout the home to promote the health and safety of residents. However, radiators and pipe work are not guarded or do not have guaranteed low temperature surfaces. Risk assessments are in place, but it is recommended that consideration be given to the fitting of suitable guards as part of the refurbishment programme, to ensure the safety of residents. 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 DS0000063469.V263151.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 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 the following standard(s): 2 and 5 Residents are issued with a contract describing Terms and Conditions of occupancy at the point of admission to the home. Prospective residents and their relatives or representatives are invited to visit the home prior to admission to enable them to assess the facilities and services provided. A trial period is also available before making any decision about whether or not to stay. EVIDENCE: All residents at Primrose Lodge are issued with terms and conditions of residence. These are signed by the resident or their representative and the registered provider. The resident and/or their representative retain a copy and a copy is held on file. A further blank copy of the terms and conditions is in the Service User Guide, which is available in every bedroom and in the entrance hall. Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 Page 10 The terms and conditions are in need of minor amendment. For example, when referring to the complaints procedure it should be made clear that a complainant may approach the Commission for Social Care Inspection at any time and not only if the complaint is unresolved. At paragraph 3, the document refers to the National Care Regulations; this should read The Care Home Regulations 2001. Reference is also made to the National Care Standards Commission; this should now read the Commission for Social Care Inspection. Mrs Mitchell says she always encourages prospective residents and their relatives to visit the home prior to admission. She feels it is helpful for them to have opportunities to look round the home, perhaps enjoy a meal and meet with other residents and staff, assess facilities and ask any questions. A trial period of four weeks is available. Residents were able to confirm that they or their relatives were able to visit the home before making any decisions about admission. Although basic information about the trial period is available in the terms and conditions or contract, it is suggested that further information detailing the opportunities for prospective residents to visit the home, sample meals etc, as well as arrange a trial period, be included in the Service User Guide, to fully reflect current good practice. Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 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 the following standard(s): 7, 9, and 11 Primrose Lodge has a detailed care planning system in place, which ensures that staff have the information they need to meet the needs of residents. There are now satisfactory arrangements in place for managing medication, ensuring that the medication needs of residents are met. Residents are treated with sensitivity and respect at the time of their death. 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. At the last inspection it was required that more information about social care needs be recorded. A good start has been made in obtaining life histories for each resident. These will provide more information about each residents background, interests etc and help to ensure that social activities are person centred, and tailored to the needs of each individual. It is hoped to see these in place at the next inspection. Until this is fully achieved, the requirement is repeated at the end of this report. Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 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 give a good picture of the care provided, including visits by community health professionals etc. At the last inspection, two requirements and a recommendation were made in respect of the arrangements for dealing with medicines at Primrose Lodge. These have now been met. Where appropriate, residents may take responsibility for their own medication. The care plan of a recently deceased resident was examined and found to be well detailed, showing that relatives had been kept informed of the situation. Health care professionals provided support to the home’s staff. Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 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 the following standard(s): 12, 14 and 15 Plans are in hand to improve the range of activities available to residents. Information about each residents social, cultural, religious and recreational needs is currently being collected, so that activities can be tailored to meet individual need and expectation. Residents are encouraged to choose their own lifestyle within the home and their individual preferences and routines are respected. Primrose Lodge serves a balanced and varied selection of food that meets residents’ tastes and special dietary needs within a variety of pleasant surroundings. Some residents felt they were not always consulted about what they would like to eat. EVIDENCE: At the last inspection, some residents commented that Primrose Lodge provided few meaningful activities. It was felt that the home was not meeting many residents expectations and preferences in terms of recreational and social needs etc. Mrs Mitchell confirmed that since this time, the views of residents have been sought regarding the changes they would like to see. An Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 Page 14 activities organiser is currently being recruited to provide a range of group and individual activities each afternoon. A start has been made in collating information about each residents background, social history, previous hobbies and interests etc. Mrs Mitchell is preparing 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. She is also seeking the views of residents with regard to their religious needs. It is hoped to see the full benefit of these planned improvements at the next inspection. 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. Residents confirmed that their individual preferences and routines are respected. I come and go as I please. I can do whatever I want. I can go out or choose to stay in my room all day, nobody minds. Residents confirmed they are consulted about what is going on in the home, including plans for new furniture in bedrooms, redecoration and activities/social events. Lunch on the day of inspection was Shepherds pie, with creamed potatoes, broccoli, cauliflower and cabbage. This was followed by apple and sultana crumble, strawberry fruit jelly with strawberry mousse or ice cream. A range of alternatives, such as fish, omelettes, salads etc is always available to suit individual taste and preference. Residents may choose to eat their meals in the lounge, dining room or in their bedrooms. Mealtimes can be flexible to fit in with care needs, appointments etc. The menu shows that residents enjoy a healthy, well-balanced diet. Specialist diets are catered for. Many residents commented favourably about the food. I think we have a very good chef. The food is not bad at all. I enjoy all my meals here. The meals here are good and the food is well cooked. However, several residents were not completely satisfied. Some said they were not always sure what was on the menu each day. For example, The menu board is not always written up-to-date, so we dont know what we are eating. Two residents said they were not consulted about what they would like for lunch. The chef is supposed to ask us what we want for lunch, but he does not always ask, he sometimes just assumes. Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 Page 15 Several residents also said they would like more fresh fruit on the menu. I wish we could have a choice of fresh fruit after the main meal, I dont always fancy a pudding. We have a very good choice of vegetables, but not fresh fruit. Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 Page 16 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 and 17 A system is in place for dealing with any complaints. Residents are confident complaints would be listened to and dealt with appropriately. However, the method of recording any complaints needs some improvement. Residents have their legal rights protected and are assisted in exercising their rights. 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. The Commission has received no complaints since Primula Care Ltd. were registered in February 2005. One complaint has been received by the home since the last inspection, but the complaints record shows this was unsubstantiated. It is recommended that investigation notes are more detailed and include outcomes and any action taken as a result. Contact with residents 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 never had to make a complaint. If I was worried about anything I would tell Debbie (manager).” I have no complaints at all, I am very settled here.” If something is wrong, I just tell the staff or Debbie and they put it right.” Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 Page 17 Mrs Mitchell said the home undertakes to assist residents in utilising their rights as fully as possible. All residents are placed on the electoral roll. During local and national elections, opportunities are made available to all residents to vote if they wish, either in person, by post or by proxy. Transport to the polling station is provided if necessary. Most residents chose to vote by post at the General Election in May 2005. The home provides information about advocacy services, where residents lack capacity or require independent support or advice. Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 Page 18 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): 21, 22, 23 and 24 Considerable investment in the upkeep and refurbishment of the home is resulting in an attractive, well-maintained and comfortable environment for residents, where standards are constantly improving. The home provides sufficient bathrooms and WCs to meet the needs of residents. Residents have the equipment they need to maximise their independence. Bedrooms are comfortably furnished and individually personalised to suit the needs of their occupants. EVIDENCE: The home has sufficient communal bathrooms and WCs to meet the needs of residents. There is an assisted bath shower room with WC on the ground floor and a bathroom with WC on the first and second floors. In addition, all but one bedroom is equipped with en-suite facilities. (In some rooms, WCs and in others, also with a bath or shower.) Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 Page 19 Hot water temperatures at baths were tested and found to be close to the recommended temperature of 43C, to prevent any risk of scalding. A suitably qualified person has undertaken an assessment of the premises and facilities to ensure they meet the needs of residents and that appropriate equipment is provided. Equipment such as a passenger lift, hoist, grab rails, raised toilet seats, toilet frames and commodes are available to assist residents, as necessary, in maximising their independence. Residents spoken with confirmed that their bedrooms suited their needs. Bedrooms are comfortably furnished and personalised to varying degrees. Primrose Lodge is registered to accommodate up to 27 residents in 4 double and 19 single bedrooms. However, the home has a policy, which states that only those who wish to share will be accommodated in a double room. At present, 3 of the 4 double rooms are used for single occupancy. A programme of refurbishment has commenced and it is planned that each bedroom will be redecorated and provided with new carpets, curtains, bed, bedding and high-quality furniture over a period of time. All rooms are centrally heated and have natural light and opening windows. Secondary lighting is also provided. Residents commented, “I have a lovely room, I am very pleased with it.” I have everything I need in my room. A tour of the building demonstrated that further improvements have taken place, as part of the refurbishment of the home. Thermostatic controls have been fitted to radiators, allowing residents to adjust the temperature as they wish in their bedrooms. New carpets have been fitted in the entrance hall, all corridors, stairways and landings. Attractive pictures, depicting local scenes, are now in place to improve the appearance of corridors. Lighting fitments in the lounge have been replaced and emergency lighting has been fitted to the exterior of the building. In the kitchen, the refrigerator, gas water heater and lighting have been replaced and a further new refrigerator is on order. Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 Page 20 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): 28, 29 and 30 Primrose Lodge is working to achieve the minimum ratio of 50 trained members of care staff at NVQ level 2, to ensure residents are in safe hands. The home has a detailed recruitment policy, which makes sure that appropriate checks are carried out prior to employment commencing, for the protection of residents. The home acknowledges the importance of staff training and is taking steps to ensure that staff are well trained and competent to do their jobs. EVIDENCE: Primrose Lodge has a dedicated team of care and support staff who are working positively with residents to ensure their needs can be met. At present, only one member of care staff has NVQ level 2. However, five staff will commence NVQ level 2 training early in 2006 and a further two staff will commence NVQ level 3 training at the same time. Mr Thomas says he hopes to exceed the minimum ratio of 50 trained members of care staff at NVQ level 2, to ensure residents at Primrose Lodge are in safe hands. Mrs Mitchell spoke confidently about the recruitment process at Primrose Lodge. The staff files examined demonstrated that the home is operating a thorough recruitment procedure, to ensure the protection of residents. Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 Page 21 The home takes staff training seriously as a means of improving the standard of care provided and ensuring residents safety. All new staff receive induction and foundation training. Mrs Mitchell is aware of the recently introduced Skills for Care Common Induction Standards and will be developing these at Primrose Lodge, in conjunction with the homes own induction and foundation training programme. A member of staff commented, This is a good place to work. I have done a lot of training since I came here. Records show that, over a period of years, staff have undertaken a variety of training such as Adult Protection, report writing, moving and handling, first aid, basic food hygiene, health and safety, infection control and the administration of medicines. Some of this training is recent, but for other staff, this needs to be updated, e.g., first aid. It is also necessary to ensure that all staff, including those more recently employed, have received training in moving and handling, infection control, first aid etc. It is recommended that a training audit be carried out to update records and ensure that all staff have received the training they need. Copies of all training certificates should be retained to provide evidence that staff receive a minimum of three paid days training per year. Residents speak highly of the staff at Primrose Lodge. The following comments are typical: - The staff here are very good, they will get you anything you need. Most of the girls (staff) here know me very well and are very good to me. Staff are very helpful and are there when you need them. They are very kind and you can have a bit of fun with them as well. Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 Page 22 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, 36 and 38 Mrs Mitchell leads by example to ensure that residents receive a consistently high standard of care. The home regularly reviews its performance and actively seeks the views of residents, staff and relatives to ensure the home is run in the best interests of residents. A formal staff supervision system is now in place, but this is not being implemented at the recommended intervals. The home endeavours to provide a safe environment for residents. However, unguarded radiators and pipework may potentially pose risks to the safety of residents. EVIDENCE: One of the conditions of registration for Primula Care Ltd is that a manager be registered with the Commission for Social Care Inspection and this has not yet Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 Page 23 been met. Mrs Mitchell has been appointed to the post of manager at Primrose Lodge, having worked previously as assistant manager. She has experience in caring for older persons and is working towards her National Vocational Qualification (NVQ) level 4 in care and management. Mrs Mitchell has now submitted her application for registration as manager with the Commission. (Since this inspection, Mrs Mitchell has been successfully interviewed for the post of registered manager at Primrose Lodge.) Meetings are also held with residents to discuss matters such as the refurbishment of the home and the provision of activities. Mr Thomas says he feels it is important to have regular contact with residents in order to make sure that the home is meeting their needs and operating in their best interests. Mrs Mitchell and her staff spend time talking with residents informally to obtain their views. Quality Assurance questionnaires have been sent out to residents, staff, relatives and other visitors to the home. Feedback from these is available in the Information File in the entrance hall. Care staff should receive 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. Examination of supervision records shows supervision taking place approximately every three months. Staff meetings also 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. 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 safety of residents, e.g. equipment, such as the lift, portable electrical appliances, hoists etc are regularly serviced and maintained. All substances that could be potentially hazardous to health are handled and stored safely and restrictors are fitted to windows. However, none of the radiators and pipework at Primrose Lodge are guarded or have guaranteed low temperature surfaces. Risk assessments are in place, but it is recommended that consideration be given to the fitting of suitable guards as part of the refurbishment programme, to ensure the safety of residents. 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 also taking place at the required intervals. Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 X X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 X X X 3 3 3 3 X X STAFFING Standard No Score 27 X 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 X 2 Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) and 15(2) Requirement Timescale for action 30/03/06 2. OP12 16(2) (m) and (n) 3. OP16 17(2) Schedule 4 All aspects of each resident s health and welfare needs, including social care needs, must be recorded and regularly reviewed. (Previous timescale of 30/11/05 still current). The registered person must 30/03/06 consult residents about their interests and provide a suitable programme of activities. (Previous timescale of 30/11/05 still current). It is required that the record of 30/03/06 complaints investigations is more detailed and includes outcomes and any action taken as a result. Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 Page 26 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 OP2 OP15 Good Practice Recommendations It recommended that minor amendments (as detailed in this inspection report) be carried out to the terms and conditions of residence document. It is recommended that the menu board in the dining room be used to inform residents of the days menu. It is further recommended that all residents be consulted with regard to what they want to eat each day. It is recommended that a minimum of 50 of care staff achieve NVQ level 2 training. It is recommended that an audit of staff training be carried out, to update records and ensure all staff are receiving the training they need. It is recommended that formal staff supervision be carried out at two monthly intervals. It is recommended that radiators and pipework are guarded, or have guaranteed low temperature surfaces, to ensure resident safety. 3 4 5 6 OP28 OP30 OP36 OP38 Primrose Lodge DS0000063469.V263151.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole 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 DS0000063469.V263151.R01.S.doc Version 5.0 Page 28 - 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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