Inspection on 26/10/05 for Priory Gardens

This inspection was carried out on 26th October 2005.

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

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

Other inspections for this house

Priory Gardens 24/10/06

Priory Gardens 15/09/04

Priory Gardens 09/06/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Priory Gardens Ladybalk Lane Pontefract West Yorks WF8 1LA Lead Inspector Patricia Pedley Unannounced Inspection 26th October 2005 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 Gardens DS0000006205.V259532.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. Priory Gardens DS0000006205.V259532.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Priory Gardens Address Ladybalk Lane Pontefract West Yorks WF8 1LA 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) 01977 602111 01977 602810 priorygardens@schealthcare.co.uk Southern Cross Healthcare Services Limited Mrs Joyce Blythe Care Home 72 Category(ies) of Old age, not falling within any other category registration, with number (72), Terminally ill (5), Terminally ill over 65 of places years of age (10) Priory Gardens DS0000006205.V259532.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. No more than ten service users who are terminally ill TI(E) One named service user under 65 years of age No more than five service users in TI category, aged between 60 and 65 years of age 23rd May 2005 Date of last inspection Brief Description of the Service: Priory Gardens provides personal and nursing Care to 72 older people, up to 10 of whom may have been admitted with a diagnosis of a terminal illness. Set back in its own grounds there is a large lawn with a drive and car parking to the front and a smaller fenced garden to the sides and rear. All accommodation offered is single and all rooms are provided with en-suite facilities. There are a number of lounges, dining rooms and a smaller lounge for service users who wish to smoke. There are also assisted bathrooms, and a passenger lift, for those service users who require them. The home is close to the centre of Pontefract and all local services and amenities. It is on a main bus route and the bus and rail stations are close by. Priory Gardens DS0000006205.V259532.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the care home, which took place over a 7-hour period. During the course of the inspection residents, staff and visitors spoke with the inspector. Some records were examined and most areas of the home visited. The registered manager was not on duty through ill health and another manager from another of the company’s homes was overseeing the home. The inspector would like to thank residents and staff for their assistance and hospitality shown during this inspection visit. What the service does well: What has improved since the last inspection? What they could do better: As mentioned in the last inspection report, there needs to be further development of individualised care plans and risk assessments, particularly on the nursing floor so that individual needs are identified as well recording the Priory Gardens DS0000006205.V259532.R01.S.doc Version 5.0 Page 6 action to be taken by staff to meet those needs. It would be useful for staff to be trained in person centred care planning as this would assist in the development of care plans. Medication records need to be accurately kept. Staff still need to attend training in adult protection procedures, including local procedures as this would help staff to have a good understanding of the action to be taken to protect people should the need occur.Staff need to be trained twice a year in fire safety. It would be beneficial to attend to the wheelchair damage to walls and doorways. 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. Priory Gardens DS0000006205.V259532.R01.S.doc Version 5.0 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 Gardens DS0000006205.V259532.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Satisfactory arrangements are made for admitting residents into the home. Care planning could be further enhanced by keeping copies of the care management assessment and care plan on the current file as this could be used as a basis for preparing the homes own care plans. EVIDENCE: The Statement of Purpose and Service user Guide were examined and found to contain the information required by regulation. Senior staff said that they go and visit prospective residents to carry out an assessment of need. Copies of the care management assessment and care plan from the funding authority are not kept on the current file although staff said that these are obtained by the home. The usefulness of keeping these on the current file was discussed. Priory Gardens DS0000006205.V259532.R01.S.doc Version 5.0 Page 9 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, 8, 9, 10 & 11 Whereas care planning is progressing well on the residential floor further work is needed to develop care planning and risk management processes particularly on the nursing floor so that staff are better informed as to how to meet residents individual needs. Action needs to be taken to address record keeping for medication to ensure that resident’s wellbeing is safeguarded. Residents appear to be well cared for by a pleasant and helpful staff team. EVIDENCE: A number of care plans were examined on both the nursing and residential floors. The manager on cover duty said that a new care planning system was being introduced and several changes had already taken place. From examining care plans on the nursing floor it was found that where new care plans had commenced that the information from the old care plan was not available but the new care plan was not sufficiently completed to inform staff Priory Gardens DS0000006205.V259532.R01.S.doc Version 5.0 Page 10 of the residents needs. The difficulties this may cause for agency staff was discussed with the manager. These care plans also covered only some aspects of a residents care for example one had care plans for only hygiene, oxygen therapy and spiritual support rather than taking a more holistic person-centred approach. One resident’s file showed there was no care plans in place. Those care plans seen on the residential floor were much better and were person centred. The member of staff who had prepared these had attended a person centred care planning course and it was pleasing to see this learning being put into practice. The manager said that this training is no longer on offer by the company at present. The senior carer said that key workers were becoming more involved in care planning and that care plans were been gone through with residents or their relatives for them to consent and agree to the contents of the care plan. New risk assessment formats have also been introduced. From records examined, primarily on the nursing floor some have yet to be completed. However those that have been completed were seen to identify that there was a risk but it was less clear what action was to be taken by staff to minimise risk and thought needs to be given as to how this can be recorded clearly. It was also noted on some assessments/care plans on the nursing floor that there was goals to be actioned such as “assess environment”, “arrange visual assessment” etc but there was no evidence of these being attended to. A note was seen in the nursing unit diary that bloods could not be taken, as there were no blood bottles as those in stock were two years out of date. This was discussed with the manager on cover duty who said that she would ensure this would be attended to. From examining the medication administration record sheets on the nursing floor it was found that there were some gaps on the record. On the residential floor some bottles had not been signed when first opened and a couple of gaps were seen on the administration record sheet. The controlled drug register showed that one medication had not been countersigned for the day previous to the inspection. Medication was being kept tidily. Medicines are kept in the office accommodation on both floors. These rooms were seen to be locked when no one was in during the inspection. The usefulness of having a separate treatment room was discussed with the manager on cover duty. The manager said that although there were staffing difficulties on the nursing floor that the personal and healthcare of residents was not being compromised and that residents looked well care for. A good number of residents spoke with the inspector. They said that they were happy and they confirmed that they were looked after by nice staff. Residents looked well in all aspects of their personal care and the hairdresser was visiting during the inspection. Priory Gardens DS0000006205.V259532.R01.S.doc Version 5.0 Page 11 Ladies said they liked going to her, as they feel better with their hair done nicely. Discussion with staff demonstrated that they have a good understanding of how to deal sensitively with incidences of death in the home. Priory Gardens DS0000006205.V259532.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 15 Satisfactory arrangements are made for residents to join in a good choice of activities. A good choice of food is on offer. EVIDENCE: Two residents had gone out shopping for the day with two staff. One resident had gone out a few days before with the activity organiser to a local nature reserve and showed the inspector her new photographs of her day out. Other residents said there were a number of activities taking place but they chose not to join in. A visitor said that the activity organiser visits the nursing unit to tell residents if there was an activity taking place on the floor above and asks if anyone wishes to join in. Some areas of the home were decorated for Halloween and residents said that they were looking forward to Bonfire night. A sample menu was seen and this looked to have a good variety of food on offer. The meal of the day looked appetising and was of good portion size. Residents said that the meal was very nice. Priory Gardens DS0000006205.V259532.R01.S.doc Version 5.0 Page 13 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 & 18 Good arrangements are in place for handling complaints. Staff would benefit from training in the local procedures for adult abuse and the mistreatment of vulnerable adults so that they have a better understanding of how to protect vulnerable older people. EVIDENCE: The record of complaints was examined and these showed that they were dealt with promptly and that the complainant was informed of the outcome. At the last inspection, it was recommended that it would be useful for staff to have the opportunity to attend the local authority training on Adult Abuse and the Mistreatment of Vulnerable Adults to inform them further of the action to be taken through local procedures should any situation arise in the home. The manager on cover duty said that no one had attended as yet but that she had provided the home with the relevant information on this training and that she herself had attended and found it informative and useful. She said that she is confident that plans will be made for staff to attend once the home’s registered manager returns to work. Priory Gardens DS0000006205.V259532.R01.S.doc Version 5.0 Page 14 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): 19, 23, 24, 25 & 26 Generally, the home was found to be clean well maintained, homely and comfortable and meets resident’s needs. This could be further enhanced by carrying out a review of mattresses/bed linen to ensure the comfort of service users and attending to walls and doors which have been marked by wheelchair use. EVIDENCE: Several areas of the home were visited. The dining areas and lounges were well presented and tables were set nicely ready for dinner. Generally, bedrooms were comfortable, homely and personalised with resident’s personal belongings. The bed on one bedroom had a plastic covering with only a thin sheet on top which slipped on the plastic surface. The manager was asked to look at this to ensure it was sufficiently comfortable for the resident to sleep or rest on. The manager on duty said that several new mattresses had just been delivered. Priory Gardens DS0000006205.V259532.R01.S.doc Version 5.0 Page 15 Generally the home is well decorated although some bedroom walls and doorways have been badly marked by wheelchairs. Residents are able to keep pets, primarily budgies and cockatiels. Priory Gardens DS0000006205.V259532.R01.S.doc Version 5.0 Page 16 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): 27 & 30, Although there are staffing difficulties caused by sickness, arrangements are in place to provide sufficient cover so that resident’s wellbeing and safety is not compromised. Staff training arrangements could be further enhanced by offering opportunities for staff to attend training on care of the elderly and person centred care planning. EVIDENCE: The manager on cover duty said that the nursing unit was being covered primarily with agency staff at present but the home was fortunate in being able to get regular nurses to cover duties so they were getting to know residents needs. She said that these cover arrangements were having to take place because of staff sickness. The manager said that the Macmillan nurses have recommended that no admissions of a terminally ill resident should take place until regular staffing is in place. The home is currently recruiting for both nursing and care staff, particularly night staff, and are awaiting references and other checks before new staff can commence. The senior carer on duty on the residential floor said that there is a good staff team upstairs, several of who have worked in the home for a number of years. There is concern in the staff team on the residential floor that they sometimes run short staffed as if they are short staffed downstairs one of Priory Gardens DS0000006205.V259532.R01.S.doc Version 5.0 Page 17 their staff has to go down to work in the nursing unit. One member of staff from the residential floor staff was working in the kitchen on the day of inspection. However, generally staffing levels are being maintained through agency cover. The manager on cover duty said she understands that the home is doing well with NVQ training for staff but was unfortunately not able to provide any figures. Staff records showed that mandatory training was taking place but there was less evidence of training taking place recently on the care of the elderly and needs associated with ageing. Priory Gardens DS0000006205.V259532.R01.S.doc Version 5.0 Page 18 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): 33 & 38 Satisfactory arrangements are in place for managing the home in the absence of the registered manager. Residents are consulted about decisions in the home, which may affect them. Although generally, good health and safety arrangements are in place this could be further improved by ensuring that staff receive two fire lectures in every twelve-month period. EVIDENCE: The homes manager was not present at this inspection as she was absent through illness. Cover for the manager is taking place through other registered managers within the company. One of these managers was present for this inspection. Priory Gardens DS0000006205.V259532.R01.S.doc Version 5.0 Page 19 The minutes of staff and residents meetings were examined. These demonstrated that consultation takes place between residents and staff. There was evidence to show that relatives meetings have also been arranged but no one has chosen to attend which has been disappointing for staff concerned. Residents and relatives who spoke with the inspector were full of praise for staff. The home now has their own moving and handling trainers in place who will carry out training of new staff and refresher training. From examining records these show that staff have not always had two fire lectures in every twelve-month period. The manager on duty said that fire training was due to take place later in the week and that a new fire risk assessment had been prepared. Since the homes registered manager was not present, a good number of the homes records were not examined during this inspection. Priory Gardens DS0000006205.V259532.R01.S.doc Version 5.0 Page 20 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 3 X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X 3 2 3 3 STAFFING Standard No Score 27 3 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 1 Priory Gardens DS0000006205.V259532.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1)(2) Requirement Holistic care plans must be in place for every resident in respect of their health and welfare. . There must be no gaps on the medication administration sheet. Bottles of medication must be signed upon the date of first being opened. The controlled drug register must be countersigned on each occasion of administration of medication. The homes manager must arrange training for all staff to ensure that they have an understanding of the homes procedures with regard to the protection of vulnerable adults and how to refer such matters using Wakefield Council’s procedures. Any incident must be referred to the funding authority as soon as the situation arises. Staff must attend two fire lectures in every twelve-month period. DS0000006205.V259532.R01.S.doc Timescale for action 31/01/06 2 OP9 13(2) 26/10/05 3 OP18 13(6) 31/03/06 4 OP38 23(4)(d) 31/01/06 Priory Gardens Version 5.0 Page 22 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 OP3 Good Practice Recommendations It would be useful to retain a copy of the care management assessment and care plan on the resident’s current file as this could be used as a basis to the homes own care planning process. Care plans need to be developed further so that they fully identify the personal care, healthcare and social needs of service users as well as setting realistic goals and expectations for staff in meeting identified individual needs. Risk assessments are in need of further development and should be reviewed so that as well as identifying if there is a risk to a resident they should also identify how this risk is to be minimised. ` It would be useful to consider the provision of a separate treatment room for the safekeeping of medication. The badly marked walls, including in resident’s rooms and doorways should be addressed. It would be useful to review how beds were dressed with linen to create a better barrier between the mattress and sheet so that they are comfortable for residents to sleep in. It would be beneficial for staff to have opportunities on the care of the elderly and person centred care planning. 2 OP7 3 4 5 OP9 OP19 OP24 6 OP30 Priory Gardens DS0000006205.V259532.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Priory Gardens DS0000006205.V259532.R01.S.doc Version 5.0 Page 24 - 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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