Inspection on 24/04/07 for Priory Court Care Home

This inspection was carried out on 24th April 2007.

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.

Other inspections for this house

Priory Court Care Home 13/02/09

Priory Court Care Home 21/04/08

Priory Court Care Home 20/01/08

Priory Court Care Home 27/09/05

Priory Court Care Home 21/06/05

Priory Court Care Home 16/09/04

Priory Court Care Home 13/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Priory Court Care Home Old Schools Lane Ewell Village Surrey KT17 1TJ Lead Inspector Sandra Holland Unannounced Inspection 24th April 2007 10:10 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.V333218.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.V333218.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 Crayden 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.V333218.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 27th September 2005 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 £ 600.00 to £ 820.00 per week. Priory Court Care Home DS0000013850.V333218.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection site visit was carried out by the Commission for Social Care Inspection (CSCI) under the Inspecting for Better Lives process. Mrs Sandra Holland, Regulation Inspector carried out the inspection over seven and three quarter hours. The inspector was assisted initially by the deputy manager and the registered manager, Mrs Susan Crayden arrived shortly after. A tour of the premises was carried out and a number of records and documents were sampled at random, including care plans, staff recruitment and training files and medication administration record (MAR) charts. Fourteen residents, ten staff and three visitors were spoken with. A pre-inspection questionnaire was supplied to the home and this was completed and returned within the requested timescale. Information from the questionnaire will be referred to in this report. The people living at the home prefer to be known as residents and this is the term that will be used throughout this report. The inspector would like to thank the residents, staff and management of the home for their hospitality, time and assistance. What the service does well: The home is cheerfully decorated, well furnished and presents as a comfortable place to live. There is an attractive, enclosed courtyard garden available for residents’ use. Residents spoke of the helpfulness and cheerful assistance of staff and staff were observed to interact with residents in a friendly and informal but appropriate way. It is clear that the staff are responsive to changes in residents’ health and seek prompt and appropriate advice. The home has an effective working relationship with the local health centre. Priory Court Care Home DS0000013850.V333218.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Priory Court Care Home DS0000013850.V333218.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Priory Court Care Home DS0000013850.V333218.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of residents are assessed before they move into the home. EVIDENCE: The individual care plans for a number of recently admitted residents were seen and a thorough pre-admission assessment of the needs of the residents had been carried out. It was noted that the pre-admission assessment for one resident had not been signed or dated, so it was not possible to know when it was carried out or by whom. The manager stated that some prospective residents are assessed when they come to visit the home and others are assessed at home or wherever they are residing. Residents spoken to advised that they had visited the home prior to moving in, which enabled them to see the facilities offered and meet other residents and staff. Priory Court Care Home DS0000013850.V333218.R01.S.doc Version 5.2 Page 9 For those residents who are supported financially by a local authority, an assessment had been carried out under the care management process. A copy of the care management assessment had been obtained and retained where applicable. Priory Court Care Home DS0000013850.V333218.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are well documented to effectively guide staff to the care and support needs of residents and residents are treated with dignity and respect. The administration of medication must be more robust to fully safeguard residents. EVIDENCE: As stated previously, the care plans of a number of recently admitted residents were sampled. The plans are used to guide staff to the support and care needs of residents, and those seen contained detailed information which had been updated as required. Risks to residents that have been identified have been assessed, recorded and where possible, minimised. Those seen included assessments of the risks associated with mobility, of developing pressure sores, risks associated with nutrition and the use of bed rails. It was noted that a number of residents use electrically operated beds or armchairs, but assessments of the risks associated with these had not been carried out. Priory Court Care Home DS0000013850.V333218.R01.S.doc Version 5.2 Page 11 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 , occupational therapist and physiotherapist. Staff stated that medication is supplied to the home by a local pharmacy and the majority of medications are packaged individually in “blister” packs, as a monitored dosage system. Printed medication administration record (MAR) charts are also supplied by the pharmacy. It was noted that some medications that had been supplied, did not have a printed MAR chart, but had been handwritten onto an existing chart. These entries had not been signed by the person making the entry, or countersigned after checking by a second person. Random checks were carried out on a number of medications and it was noted that the receipt of recently received medications had not been recorded. For two medications which could be given in a variable dose, it was not possible to know the quantity of medication that should be present, as the dose actually administered had not been recorded. For another medication, which was being recorded as a controlled medication, it was noted that a number of tablets had been removed from the original bottle as they did not appear to be the prescribed medication, leaving a shortfall in the number that should be present. The medication for one resident had been supplied to the home by the pharmacy in original packaging. The medications had then been dispensed into divided trays for administration, but this creates an increased risk of medication errors. Staff were seen to treat residents with respect, speaking in a relaxed and friendly but appropriate manner. Resident’s privacy was promoted, with staff taking care to knock on resident’s bedroom doors before entering and providing personal care in a tactful and discreet way. An immediate requirement has been made regarding Standard 9 and a requirement has been made regarding Standard 7. Priory Court Care Home DS0000013850.V333218.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered a range of leisure activities, although the hours worked by activities staff need to be reviewed. Residents are supported to maintain contact with their families and friends and to make their own choices. EVIDENCE: A range of activities are scheduled each month and these are advised to residents in the Priory Court Chronicle, a monthly newsletter. The April edition was seen and was attractively decorated with an Easter decoration. The activities listed included exercises, bingo, painting, crafts, quizzes, cooking and cards and dominoes. A film afternoon is planned each month and takes place in the well equipped cinema room. A number of residents were enjoying indoor games and musical activities on the day of inspection, but other residents were sitting in their rooms or were unoccupied in lounges. A small number of residents also require one to one social support due to their infirmity. From the information in the pre-inspection questionnaire, it was observed that activities staff are currently only available to support residents with their social Priory Court Care Home DS0000013850.V333218.R01.S.doc Version 5.2 Page 13 and recreational needs for thirty six hours each week. These hours are arranged from Mondays to Fridays and this equates to less than half an hour per week for each resident, when time has been allowed for planning and organisation. It was also noted that in the April chronicle, no activities were available for one week as the activity staff member was not available. To ensure that the social and cultural needs of all residents are met the hours worked by the activities staff must be reviewed and should include activities across the whole week. A number of visitors were seen at the home or were taking residents out during the course of the inspection. Staff advised that relatives are welcomed to join residents for meals and smaller, more private sitting rooms are available on both floors to enable residents to meet with their families and friends. Staff were seen to offer residents choices and to encourage residents to be independent wherever possible. The lunchtime meal which was served on the day of inspection appeared appetising and wholesome. There was a choice of two main courses, both of which had been offered to residents the previous day, to enable them to make a choice. Staff advised that further alternatives, including salad, omelette or filled jacket potato were available to residents, if preferred and residents confirmed they were aware of this. From information supplied in the pre-inspection questionnaire, it was clear that specialist diets, including those for differing ethnicities can be accommodated, and currently diabetic and pureed diets are provided in addition to the main menu. The weekly menu was displayed for residents to see and advises that snacks are always available on request. 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. There are a number of dining rooms on both floors of the home, each seating a small number of residents. Dining tables were attractively set with tablecloths, napkins and flowers and staff were observed assisting residents with their meals in a sensitive manner. A requirement has been made regarding standard 12. Priory Court Care Home DS0000013850.V333218.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are appropriately managed and staff are aware of their responsibilities in the protection of residents. EVIDENCE: A complaints policy and procedure is available in the home, has been supplied to all residents since the last inspection and is included in the service user’s guide, the manager stated. As required at the last inspection, the complaints procedure now includes the contact details of CSCI. Information in the pre-inspection questionnaire indicated that a number of complaints had been received during the past year. These were discussed with the manager and she advised that many of the complaints had related to problems with the heating system in the home, which had now been resolved. The manager stated that any complaint would usually be made verbally to the person in charge and this would be addressed immediately to resolve it and to reduce the need for further action being required. From speaking to residents and visitors, it was clear that they felt able to approach staff or the manager with any complaints or concerns. The manager and staff were observed to interact with residents in an informal and friendly manner, whilst maintaining respect and dignity. Priory Court Care Home DS0000013850.V333218.R01.S.doc Version 5.2 Page 15 Staff spoken to stated that they would report any concerns they had about the abuse or potential abuse of residents, to the manager or the person in charge, and would not hesitate to do so. Staff were aware that they could report any concerns to senior management in the St Cloud Care organisation or to agencies outside the home if needed. A number of staff advised that they had received training in the safeguarding of adults (formerly known as the protection of vulnerable adults). A Whistleblowing policy is available to staff to guide them in the anonymous reporting of concerns and a copy was seen displayed in the home. The manager stated that in the event of an allegation or incident of abuse, the home would follow the Surrey Multi-Agency procedure for Safeguarding Adults. The home’s copy of this procedure could not be found and it is recommended that a copy is obtained and retained in the home, for referral if needed. A recommendation has been made regarding Standard 18. Priory Court Care Home DS0000013850.V333218.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home presents as a comfortable place in which to live and was colourful, clean and appeared hygienic. 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. Overall the home was attractively decorated in a range of colours, with coordinating soft furnishings and is furnished to meet the needs of residents. A large enclosed courtyard garden was accessible from a number of areas of the home and raised flowerbeds in the garden are available to be tended by Priory Court Care Home DS0000013850.V333218.R01.S.doc Version 5.2 Page 17 residents, if they wish to. Residents and their visitors were seen and spoken to, whilst sitting on benches and enjoying the garden. As a high number of residents are wheelchair users or have high level needs, the home suffers a lot of wear and tear. It was noted that the paintwork in a number of areas needed refreshing. The manager stated that residents’ bedrooms are decorated when they become vacant to ensure that they are fresh for new residents when they move in. From information supplied in the pre-inspection questionnaire it was noted that a maintenance worker is employed at the home, but only works for twenty hours each week. As the home is a large building, accommodating sixty residents, the hours worked by the maintenance worker should be reviewed to ensure that all maintenance tasks can be effectively carried out. All areas of the home were very clean, tidy and appeared hygienic. Handwashing facilities with liquid soap and paper towels are provided in appropriate places and staff were seen to use these. Staff were also observed to use personal protective equipment, including aprons and gloves, to prevent the spread of infection. 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. A recommendation has been made regarding Standard 19. Priory Court Care Home DS0000013850.V333218.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A full complement of trained staff are employed to meet residents’ needs. Recruitment practices in the home must be improved to fully protect residents. EVIDENCE: From information supplied in the pre-inspection questionnaire, it was clear that a full team of staff are employed to meet the needs of residents. These include care staff, nursing staff, housekeeping staff, kitchen staff, a maintenance worker, activities staff and administrator. The information provided also confirmed that 70 of care staff have achieved National Vocational Qualifications (NVQ), to level 2 or higher and this exceeds the recommended fifty per cent of qualified staff. The recruitment files of a number of staff were randomly sampled. It was noted that at least two staff, including a qualified nurse, had been employed to work at the home before all the required checks had been carried out or the required documents obtained. As stated above, a qualified nurse was employed and permitted to work unsupervised for a number of months before a Criminal Record Bureau (CRB) disclosure had been obtained. Two references were obtained for this Priory Court Care Home DS0000013850.V333218.R01.S.doc Version 5.2 Page 19 employee, but one was dated a week after the nurse had started work and the other was dated ten months after the employee’s start date. For another member of staff, no application form was held on file and this person had been permitted to start work at the home before their CRB was obtained. There was also no evidence that a check of the POVA register had been carried out before this person was allowed to start work, pending the CRB disclosure. Individual staff training records are maintained and these were seen to record the training undertaken by each member of staff. This included fire safety, first aid, moving and handling and safeguarding adults. A training schedule is also maintained by the manager to enable monitoring of staff training needs. It was noted from the training schedule, that a number of staff require training specific to their role. From the records seen, none of the housekeeping or maintenance staff have undertaken training in the Control Of Substances Hazardous to Health (COSHH), and three of the kitchen staff have not undertaken food hygiene training. Most of the care staff have not undertaken food hygiene training, although they are involved in the serving of food and assisting residents with their meals. There is cultural and racial diversity amongst the staff team although the resident group is predominantly British. The majority of staff are female which is reflected in the resident group. An immediate requirement has been made regarding Standard 29 and a requirement has been made regarding Standard 30. Priory Court Care Home DS0000013850.V333218.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed by a person who is fit to be in charge and residents’ financial interests are protected by the home’s policies and procedures. The health and safety of residents is promoted, but is not being protected. EVIDENCE: The manager has many years experience in care and stated that she has worked at the home for approximately eighteen years. The manager has carried out a number of care roles and progressed to deputy manager before being appointed as manager. The manager stated she has undertaken training to enable her to carry out her role more effectively, including NVQ Level 4 in care and management and the NVQ Registered Manager’s Award. The manager is also qualified as an NVQ assessor and verifier. Priory Court Care Home DS0000013850.V333218.R01.S.doc Version 5.2 Page 21 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 who is a qualified nurse, oversees the nursing unit, supported by two head nurses. A quality survey was supplied to residents in June 2006, the manager stated, to obtain their views on the standard of the service provided. The responses were not available in the home the manager advised, as they had been sent to the St Cloud organisation head office, and a copy had not been retained. Visits to the home are carried out by representatives of the St Cloud organisation, under the requirements of Regulation 26 of The Care Homes Regulations 2001 (As Amended). This regulation requires organisations to monitor the standard of the service provided by making visits to the home. During the visit the representative should speak to residents, visitors and staff, look around the premises and write a short report and copies of these reports should be kept in the home. The administrator advised that monies are held for safekeeping for a number of residents. To safeguard residents’ finances, only administrative or senior staff 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. As noted previously at Standards 9 and 29, the health, safety and welfare of residents are not being fully protected due to the poor quality of the administration of medication and the recruitment of staff. A requirement has been made regarding Standard 33. Priory Court Care Home DS0000013850.V333218.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Priory Court Care Home DS0000013850.V333218.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 13 (4) Requirement The risks associated with the use of electrically operated equipment, including beds and armchairs, must be assessed. The receipt of medication into the home must be recorded, the amount of medication held in the home must accurately match the record held and the records held must enable an audit trail to be followed. The hours worked by the activities staff must be reviewed to ensure they are sufficient to meet the social and recreational needs of residents. 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. Staff must receive training appropriate to the work they are DS0000013850.V333218.R01.S.doc Timescale for action 24/04/07 2 OP9 13 (2) 24/04/07 3 OP12 16 (2) 26/06/07 4 OP29 19 24/04/07 5 OP30 18 27/07/07 Priory Court Care Home Version 5.2 Page 24 6 OP33 24 7 OP38 12 to perform, including food hygiene training and training in control of Substances Hazardous to Health (COSHH). A copy of the report of any quality survey carried out in the home must be made available to residents and supplied to CSCI. The home must be conducted to promote and protect the health and welfare of residents. The standards of medication administration and recruitment of staff must be improved to safeguard residents. 27/07/07 24/04/07 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 OP18 Good Practice Recommendations It is recommended that a copy of the Surrey Multi-Agency Procedure for Safeguarding Adults (formerly the Protection of Vulnerable Adults), is obtained and kept in the home, for staff to refer to if needed. It is recommended that the hours worked by maintenance staff are reviewed to ensure they are sufficient to adequately maintain the premises to the required standard. 2 OP19 Priory Court Care Home DS0000013850.V333218.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection 4630 Kingsgate Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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. 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