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Inspection on 21/04/08 for Priory Court Care Home

Also see our care home review for Priory Court Care Home for more information

This inspection was carried out on 21st April 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.

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

All residents, prior to admission to the home, receive a full assessment of their health needs. Residents spoken to on the day of the inspection were complimentary about the staff and standard of care they received. The menus sampled demonstrated that residents receive a varied diet with choice available. One resident said that she had sent a kind note to the chef requesting more plain food and the chef had listened to her request. Resident meetings are held regularly and minutes are kept.

What has improved since the last inspection?

Seven requirements were made following the inspection in April 2007 and these have now all been met. Risk assessments are now all in place for all electrically operated equipment and are in the care plans of the residents that have this equipment. All medication coming into the home is now recorded and the records kept match the medication in the home. The hours worked by the activity staff was reviewed at the time. The employment issues regarding CRB`s have now been resolved, as all staff have a CRB check prior to starting work. Staff received training in food hygiene and Substances Hazardous to Health (COSHH). The quality survey was made available to the management of the home prior to being sent to the head office. Health and welfare of residents have been protected by improved medication procedures and the improved recruitment of staff.

What the care home could do better:

Four requirements were made as a result of this inspection. The home must update its statement of purpose and service user guide to reflect the regulations.An accurate record of all complaints must be kept and be accessible to the person in charge and to CSCI. All staff must receive regular training in safeguarding adult procedures. Persons must not be employed to work in the care home unless the required information and documents as specified in Schedule 2 of The Care Homes Regulations 2001 (As Amended) have been obtained.

CARE HOMES FOR OLDER PEOPLE Priory Court Care Home Old Schools Lane Ewell Village Surrey KT17 1TJ Lead Inspector Lesley Garrett Unannounced Inspection 21st April 2008 10:00 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 Priory Court Care Home DS0000013850.V361051.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. Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Priory Court Care Home Address Old Schools Lane Ewell Village Surrey KT17 1TJ 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) 0208 3930137 0208 3941905 manager@priorycourtcare.plus.com St Cloud Care Plc Ms Susan Elizabeth Eacott Care Home 60 Category(ies) of Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (53) of places Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/age range of the persons to be accommodated will be: 65 YEARS AND OVER Of the 60 service users accommodated, 30 may be accommodated for residential care and 30 may be accommodated for nursing care. The Category Dementia - over 65 years of age DE(E) is a decreasing category, no further service users within category DE(E) must be admitted to the home. 24th April 2007 Date of last inspection Brief Description of the Service: Priory Court is a large detached, purpose built property which is built around a central courtyard garden. The home is situated very close to Ewell village which has a range of shops, pubs, restaurants and a library. Epsom town centre is a short drive away and has a more extensive range of shops and facilities. The service is registered for sixty older people and provides residential care on the ground floor and nursing care on the first floor. Up to seven of the people living at the home may have dementia. Two passenger lifts ensure that both of the two floors are accessible to those living at the home. The fees at this service range from £ 665.00 to £ 895.00 per week. Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection of the care home was an unannounced ‘Key Inspection’. Mrs L Garrett Regulation Inspector carried out the site visit and the deputy manager for the service and senior carer for the residential floor represented the service. For the purpose of the report the individuals using the service will be referred as residents, individuals or people who use the service. The inspector arrived at the service at 10:00 and was in the home for seven and a half hours. It was a thorough look at how well the home is doing. It took into account information provided by the home and any information that CSCI has received about the service since the last inspection. The Commission did not send questionaires to people associated with the service. Instead the inspector spent time during the site visit talking to some of the residents and members of the staff team. The home had supplied the commission with a documented Annual Quality Assurance Assessement (AQAA) some detail of which has been included within the report. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Documents sampled during the inspection included the home’s care plans, daily records and risk assessments, medication procedures, staff files, a variety of training records and health and safety records and Regulation 26 recorded visits by the responsible individual. From the evidence seen by the inspector it is considered that the home would be able to provide a service to meet the needs of residents who have diverse religious, racial or cultural needs. Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Four requirements were made as a result of this inspection. The home must update its statement of purpose and service user guide to reflect the regulations. Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 Page 7 An accurate record of all complaints must be kept and be accessible to the person in charge and to CSCI. All staff must receive regular training in safeguarding adult procedures. Persons must not be employed to work in the care home unless the required information and documents as specified in Schedule 2 of The Care Homes Regulations 2001 (As Amended) have been obtained. 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. Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 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 Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 13&6 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. Prospective residents only move into the home following an assessment and feel confident that their needs can be met. To enable residents to make that decision the statement of purpose and service user guide need to be updated. EVIDENCE: The service user guide and statement of purpose is given to all prospective residents prior to admission. These documents were observed and all the necessary information required was not in place to allow prospective residents all the information to make an informed decision. Both of these documents need to be checked against the regulations to ensure they contain all the necessary information. The service user guide is not kept in each individual bedroom. Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 Page 10 Six individual plans of care were sampled and pre-admission assessments were in place for all of the residents. The deputy stated that herself, a senior carer or another nurse do all of the pre-admission assessments to ensure that the home can meet the needs of prospective residents. The deputy stated that all prospective residents could visit the home prior to admission. The deputy also stated that all admissions are on a trial basis and that this is written in the contract prior to admission. Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 & 10 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. Health and personal care that residents receive is based on their individual needs. Respect, privacy and dignity are maintained at all times with medication procedures followed. EVIDENCE: Six individual care plans were sampled and these contained a variety of care plans that detail the help and support each resident may need. The deputy manager said that the home is changing their documentation and some plans contain old and new documentation. It was observed that the new documentation does not contain an area where the residents are able to sign to say they agree with the care plans and this will be a requirement at the end of the report. Risks to residents that have been identified have been assessed, recorded and where possible, minimised. Those seen included assessments of the risks Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 Page 12 associated with mobility, of developing pressure sores, risks associated with nutrition and the use of bed rails. It was clear from the records seen and speaking to staff and residents that residents’ healthcare needs are well met. A number of healthcare professionals are involved in the support of residents, including general practitioners (GP’s), community nurses, a chiropodist, an occupational therapist and a physiotherapist. The deputy stated that each resident could retain his or her own GP if the resident requested this and the GP is willing to continue. The home had a specialist pharmacy inspection in September 2007. The carer told the inspector that requirements made at that time have now been completed. The carer told the inspector that staff on the residential floor have training every year. Staff were seen to speak to the residents in a calm and respectful way and were observed to knock on the doors before entering. All bedroom doors have locks available, but the deputy manger stated few residents want to lock their door. Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 & 15 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. Residents who use the service are able to make choices about their lives and recreational activities meet their expectations. The food served at the home is of a good quality. EVIDENCE: The home has two activity organisers, which ensures that most days there is something for the residents to enjoy. The activity programme for the month was seen and it showed that the home has a varied programme. The activity organiser stated that social care plans are also kept and are also evaluated. These are kept with all the other care plans and are updated regularly. The activities are similar to those seen at the inspection in April 2007. They included exercises, bingo, painting, crafts, quizzes, cooking, cards and dominoes. A film afternoon is planned each month and takes place in the cinema room. The activity organiser also stated that the variety and type of activity in the home is discussed at the resident meetings held every three months and minutes are kept. Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 Page 14 The activity organiser and deputy manager both said that the home has good links with the local school. The children visit for special occasions at Christmas and Harvest Festival to sing and visit the residents. It was also stated that St George’s day this month would be celebrated. Communion is held one a month on a Sunday and the local priest also visits the home. The deputy manager stated that the home is able to cater for all religious beliefs. Staff were seen to offer residents choices and to encourage residents to be independent wherever possible and this was also documented in care plans. The deputy manager said that the home was choice led so that staff are encouraged to offer choice for all activities of daily living. The weekly menu was displayed for residents to see and demonstrated that a variety of meals are on offer with choice available. One resident spoken to stated ‘the food is really good I can’t complain about that’. Another resident said ‘we are always eating it’s really nice’. A small number of residents require a very specialised form of nutrition known as PEG feeding and staff have received training to enable them to support residents with this. One resident stated that she had written a friendly letter to the chef recently to request plain food without too much sauces. She said the chef had listened and that that things had improved. There are a number of dining rooms on both floors of the home, each seating a small number of residents. Dining tables were set with tablecloths, napkins and flowers, and staff were observed assisting residents to their places for supper. They were engaged in conversation with one another deciding what to have to eat. Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. The complaints and safeguarding procedures and practices in the home need to be strengthened to protect the residents. EVIDENCE: The home has a complaints policy, which is displayed for all residents to see. The address given for CSCI is out of date and this must be corrected. The complaints log does not contain all of the most recent complaints to the home. Regulation 37 notices sent to the commission confirm that two complaints had been received by the home recently but these are not in the current log. A complainant had also contacted the commission and the link inspector had spoken with the area manager about this concern. This also does not appear in the complaints log but the deputy manager said that she was aware of this concern. A requirement will be made at the end of the report. When speaking to some of the residents during this inspection they told the inspector that they knew how to make a complaint and to whom. The AQAA supplied by the home made no mention of safeguarding adult’s procedures within the home. The home has now obtained the most recent local authority procedures and the deputy manager said these are the procedures Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 Page 16 they follow. The deputy manager stated that all staff receive safeguarding training every year. Training records were sampled and seven members of staff had received training this year since January. According to the training records for last year no safeguarding training took place. Only one member of staff that the inspector spoke with said they had received recent training in the procedures. During a meeting between the commission, the registered manager and the deputy manager assurances were given that this training will be a priority in 2008. Three employment records were sampled but it was observed that none of these folders had explanations for the gaps in employment. The manager and deputy manager during the meeting stated that steps had been taken to look at recruitment practices. The deputy manager stated that she had attended the local authority training in 2004 and the senior carer had received her training in 2000. Both members of staff confirmed they had attended the home’s training. It will be a requirement at the end of the report that all members of staff receive regular safeguarding training and recommend that the senior members of the team access the local authority training also. Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 Page 17 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 & 26 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. The design and layout of the home enables people to live in a safe wellmaintained and comfortable environment. EVIDENCE: The home has been purpose built and is arranged over two floors, with two passenger lifts providing access to both floors. The ground floor is used as the residential unit and the upper floor houses the nursing unit. All resident bedrooms have an en-suite toilet and basin and a number of rooms also have an en-suite shower. A number of lounges and dining rooms are situated on both floors. The atmosphere in the home was calm and quiet with some residents observed sitting in the lounge and some remaining in their bedroom. The location and Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 Page 18 layout of the home remains suitable for its stated purpose. Some areas of the home are still in need of painting and refreshing. The deputy manager stated that the home has a maintenance person and it was a recommendation that the hours of this person be reviewed. This remains a part time position. The AQAA states that a redecoration programme to maintain a nice environment is something the home could do better. The laundry is situated at the end of a corridor and is away from food preparation and serving areas. It is well equipped with the appropriate facilities and is staffed by an allocated member of laundry staff. It was observed that hand washing facilities throughout the home were available with liquid soap and paper hand towels. The AQAA states that the proposed building schedules to erect a dementia unit will be cause minimal disruption to the residents. Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 Page 19 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 & 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. Recruitment practices in the home must be reviewed to ensure that residents are protected. EVIDENCE: The deputy manager said that dependency level assessments for all residents are completed every three months and in between if necessary. The staff rotas are then completed according to this document. The staff rotas were seen during the inspection and the deputy stated that staffing levels were adequate for the number and dependency of the residents during the day. One resident said ‘the staff are so kind to me’ and another said ‘the staff are absolutely wonderful. They are very busy but kind’. Other residents spoken to confirm that bells are answered fairly promptly but that they understood if there was a delay, as they knew staff were busy. The night rota was seen and this demonstrated that five staff in total covers the night shift with two members of staff on the ground floor and three upstairs one of which is a nurse. Due to the layout of the building and the number of residents that can be accommodated consideration should be given to complete a dependency level assessment for the night shift. The deputy Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 Page 20 manager stated that staff helped each other on both floors and it was particularly busy when two members of staff were doing the medication rounds. The information provided also confirmed that many of the care staff have achieved National Vocational Qualifications (NVQ), to level 2 or higher. The AQAA states that the plans for improvement over the next twelve months are for all care staff to have achieved level 2 standard. The senior carer stated that she and another member of staff are NVQ assessors. Three employment records were sampled but it was observed that none of these folders had explanations for the gaps in employment. A requirement about recruitment was made following the inspection in April 2007 and this will be repeated although not for the same issues identified at that time. The requirement will also state that all employment records should be reviewed to ensure that all necessary documentation is in place. The deputy manager showed the inspector the training matrix for January to December 2007. There was no evidence that the mandatory training had taken place for example fire awareness, manual handling, safeguarding adults, infection control or first aid. Staff spoken to on the day all confirmed that they receive training but they could not remember when this was. Following receipt of the draft inspection report the manager provided CSCI with an updated training matrix, which did, evidence a variety of training had taken place in 2007. The training plan for 2008 confirmed that some training had commenced and one member of staff stated they had attended one session already this year. The AQAA states that the home could conduct more training and over the next twelve months the training matrix will identify the training subjects needed. Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 Page 21 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 & 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Management at the home is good and residents’ financial interests are protected by the home’s policies and procedures. The health and safety of residents is promoted. EVIDENCE: The manager was not available on the day of inspection and the deputy had returned that morning from annual leave. The deputy manager stated the manager is registered to manage the entire home, but advised that she oversees the day to day management of the residential unit, supported by a team of senior care staff. The deputy manager is a qualified nurse and oversees the nursing unit, supported by two head nurses. Due to the absence Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 Page 22 of the manager the area manager has reviewed the arrangements at the home. She e-mailed the deputy during the inspection to confirm that the deputy will now take on the manager’s role on a temporary basis. The home must ensure that there is adequate staff cover during this period. The deputy manager stated that a quality survey was supplied to residents in 2007 to obtain their views on the standard of the service provided. The deputy advised that the responses were not available in the home, as they had been sent to the St Cloud organisation head office and a copy had not been retained. A recommendation will be made at the end of the report for these surveys to be made available to the management in the home to allow them to write any necessary action plans. It is also recommended that surveys be sent to other stakeholders in the home, for example, relatives and visiting health care professionals. The deputy stated that every month the home completes a quality audit on different topics for example a room and equipment audit, training and complaints. The area manager also visits the home every month to complete a quality audit. This regulation requires organisations to monitor the standard of the service provided by making visits to the home and requires that during the visit the representative should; speak to residents, visitors and staff; look around the premises; and write a short report, with copies of these reports being kept in the home. The deputy stated that these visits are always announced. A further recommendation will be made for these visits to be unannounced as stated in Regulation 26. The deputy advised that monies are held for safekeeping for a number of residents. To safeguard residents’ finances, only the administrator or manager have access to these and two signatures are recorded for each transaction. Residents are also provided with a lockable facility in their bedrooms, in which to store any valuables. During the tour of areas of the home, no hazards to the health or safety of residents were observed. From information supplied, it is clear that the required maintenance and checks on systems and equipment in the home are carried out to the required frequency, to promote the safety and welfare of those who live and work at the home. A check was made on the fire alarm testing log. It had not been completed since 7th January 2007 although staff confirmed that the alarms are activated regularly. It is recommended that all records be completed regularly and accurately. Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 Page 23 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 2 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 4&5 Requirement The home must update their statement of purpose and service user guide to reflect the regulations. An accurate record of all complaints must be kept and be accessible to the person in charge and to CSCI. All staff must receive regular training in safeguarding adult procedures. Persons must not be employed to work in the care home unless the required information and documents as specified in Schedule 2 of The Care Homes Regulations 2001 (As Amended) have been obtained. All records held should be reviewed to ensure that all the information is in place. Timescale for action 21/06/08 2. OP16 22 21/05/08 3. 4. OP18 OP29 13(6) 19 21/06/08 21/06/08 Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 Page 25 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. 3. Refer to Standard OP7 OP18 OP27 Good Practice Recommendations The home should consult with the residents when writing their individual care plans. It is recommended that the senior members of staff within the home access the local authority’s training in safeguarding adult’s. It is recommended that dependency levels be completed for both floors for the night shift due to the lay out of the building and the number of residents accommodated to ensure that there is sufficient numbers on duty at all times. It is recommended that the area manager completes unannounced Regulation 26 visits to the home to ensure high standards are maintained. It is recommended that the fire alarm log is kept up to date and all activations of the fire alarms are recorded. 4. 5. OP33 OP38 Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Priory Court Care Home DS0000013850.V361051.R01.S.doc Version 5.2 Page 27 - 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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