Inspection on 02/04/08 for Priory Manor [formerly Trebursye Manor]

This inspection was carried out on 2nd April 2008.

CSCI found this care home to be providing an Adequate service.

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

Other inspections for this house

Priory Manor [formerly Trebursye... 24/02/09

Priory Manor [formerly Trebursye... 25/07/07

Priory Manor [formerly Trebursye... 10/01/07

Priory Manor [formerly Trebursye... 04/07/06

Priory Manor [formerly Trebursye... 01/12/05

Priory Manor [formerly Trebursye... 27/06/05

Priory Manor [formerly Trebursye... 12/10/04

Priory Manor [formerly Trebursye... 07/06/04

Priory Manor [formerly Trebursye... 01/10/03

Priory Manor [formerly Trebursye... 26/06/03

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Priory Manor [formerly Trebursye Manor] Trebursye Launceston Cornwall PL15 7ES Lead Inspector Antonia Reynolds Unannounced Inspection 2nd April 2008 11:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.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 Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Priory Manor [formerly Trebursye Manor] Address Trebursye Launceston Cornwall PL15 7ES 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) 01566 774752 01566 775559 www.healthcare-trust.com HealthCare Trust Limited ****Post Vacant**** Care Home 54 Category(ies) of Dementia - over 65 years of age (29), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (29), Old age, not falling within any other category (29) Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service users in the category of MD may be admitted at age 55 years and over. Service users to include three named individuals under the age of 55 years in Lansye. Service users to include one named individual under the age of 65 years in Lakeside. Total number of service users not to exceed a maximum of 54 Date of last inspection 25th July 2007 Brief Description of the Service: Priory Manor is a care home providing personal care and accommodation for up to fifty-four people, over the age of 55, who may have dementia or mental health needs. Occasionally the home also accommodates some younger people with mental health needs. The home does not provide intermediate care. The home is privately owned by HealthCare Trust Ltd, and the directors also own other care homes in the South West of England. The fee levels were not provided to the Commission for Social Care Inspection during this inspection. Information about the home and copies of inspection reports can be obtained from the home. Priory Manor has been a care home for many years and was purchased by the present owners in 2003. It is in a rural area approximately two miles from the centre of Launceston. It consists of a large detached three-storey building, with a connecting two-storey annex, which is being refurbished. At the time of inspection there were 27 single bedrooms, one double room and a small flat available for residents. These are situated on each floor of the house and there is a shaft lift in the main house. Many of these have en suite toilets with some having en suite baths/showers. Bathing/showering and toilet facilities are available on each floor, close to bedrooms and communal rooms. There are large lounge and dining rooms on the ground floor and an activities/dining room on the 1st floor. Smoking is not permitted within the home but a covered outside shelter is provided at the rear of the building. The home stands in its own grounds and is approached by a long drive off a side road from the main A30. The only public transport is taxis, therefore the home has its own car for service users. Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.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 1 star. This means the people who use this service experience adequate quality outcomes. This key inspection consisted of an unannounced visit between 11.15am and 4.35pm on Wednesday, 2nd April 2008, and three further visits between 10.15am and 5.05pm on Friday, 4th April 2008, 11.20am and 3.15pm on Thursday, 10th April 2008 and 8.35am and 12.15pm on Monday, 14th April 2008. Two inspectors were present during the visit on 10th April 2008. The Acting Manager, Yvonne Osborne, was present and available for consultation throughout each visit. The Responsible Individual for the home, Raeema Patel, was also present during the second visit and for the latter part of the last visit. A tour of the premises took place and records/documents relating to the care of the service users, staff and the home were inspected. Seventeen people who live in the home were spoken with, thirteen of whom were spoken with at length. Survey forms were left for fourteen people to complete if they wished to and all of them were returned. Survey forms were sent to nineteen relatives and five were returned. Eight staff members were spoken with during the visits and others were observed in the course of their normal duties. Survey forms were sent to fourteen staff members and none were returned. Verbal information was received from health and social care professionals. What the service does well: What has improved since the last inspection? The refurbishment of the main house is virtually complete and this is to a high standard. The annex (consisting of two units known as Trelawney and Lansye) has been closed (apart from a bedroom and a flat, which are occupied) so that the planned refurbishment of these areas can take place. Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 6 The recruitment procedure for new staff has improved and the Acting Manager is aware that new staff must not carry out unsupervised personal care with service users until all the required checks and references are received. The home is no longer storing large amounts of medication and has returned everything that is not needed to a pharmacy. The fire exit from the laundry has been cleared of moss and overhanging plants to reduce the risk of accidents to staff. What they could do better: The Registered Person must produce an up-to-date statement of purpose and service user guide. This is so that prospective residents have the information they need to make an informed choice about where to live and so that everyone who lives in the home knows what facilities and services are available to them. Care plans must contain comprehensive, detailed information about the care needed by residents. Risk assessments must clearly detail the risks people may experience either because of health care needs, risks they may pose towards others and risks of self-harm. This is to ensure that staff know what care they are to provide, in what way it is to be provided, and to achieve consistency between different staff members. This information should be kept in a secure place at all times to ensure that confidentiality is maintained. Records pertaining to residents must be held in the home for at least three years after the date of the last entry. This is so that staff in the home can access a person’s history and the records are available for inspection, if required. Social and community activities should be more varied, interesting and innovative to match the residents’ preferences and satisfy their social, cultural, religious and recreational interests. Where requested, people who live in the home should be assisted with making telephone calls to relatives, and relatives should be kept informed about changes in care needs and about events/activities taking place in the home. The type of information to be shared with relatives should be agreed when a person is admitted to the home. Communication needs to be improved between the management in the home and the relatives and representatives of people who live in the home. This is to ensure that relatives/representatives are kept up-to-date and fully informed of any changes in the care needs of residents, as well as what is happening in the home. The complaints procedure should be updated with the new postal address and telephone number for the Commission for Social Care Inspection. This is so that people who live in the home, and their relatives/representatives, know how to contact the CSCI should they need to. Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 7 People who live in the home should be helped to exercise choice and control over all aspects of their lives. No changes to a person’s life, such as moving or sharing bedrooms, should take place without proper consultation and agreement with the person concerned and relatives/representatives if appropriate. A menu for each day should be available to remind people what meals are on offer for that day. All the staff need to receive training, and feel confident, in managing situations of verbal and physical aggression. The procedure for safeguarding people in the home needs to reflect the local multi-agency procedure to ensure that every incident is reported promptly and investigations are managed appropriately. All staff should attend the safeguarding (alerter’s) training provided by the Local Authority. This is to ensure that staff are aware of local procedures to follow should an untoward incident occur. The number of staff on duty at all times needs to be reviewed and, in particular, the numbers of staff on duty at night must be increased. This is to ensure that there are enough staff on duty to meet the health and social care needs of people who live in the home and that people are protected from any possible risks to their health, safety and wellbeing. Recruitment procedures must be improved and be consistently robust enough to protect people who live in the home from risk of harm. At least 50 of the care staff should have a care qualification to at least a level 2 National Vocational Qualification (NVQ). This is so that staff are trained and competent to care for the people who live in the home. Fire safety precautions must be followed and the Registered Provider needs to ensure that staff understand and can implement fire procedures. This is so that residents are protected from the risk of fire and staff know what to do in the event of a fire. A system should be provided in the laundry so that staff can summon assistance if they need to. Some attention to detail is needed regarding the environment of the home, such as the consideration of installing a call bell system so that residents and staff can summon assistance if they need it; providing suitable window coverings; making sure that doors to en suite facilities close properly; making sure that bedroom door locks are suitable and work properly; and providing each person with lockable storage space. Each person should be given a key to his or her own bedroom door and lockable storage space, unless a risk assessment suggests otherwise. The quality assurance system, as well as monthly visits by a nominated person, needs to be reinstated to review and improve the quality of care provided. This is so that the management of the home can measure how well the home is achieving goals for people who live in the home. Please contact the provider for advice of actions taken in response to this Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 8 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 Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 9 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 Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 10 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): Standards 1 and 3 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. The home’s admissions procedure ensures that prospective residents and their relatives/representatives know that the home will meet their needs. There is insufficient information available for prospective residents to make an informed choice about whether they wish to live in this home. EVIDENCE: The home had a Service User Guide available but it had not been updated since 2006. No Statement of Purpose could be found during the inspection. During the previous inspection a discussion took place with the Registered Manager about making sure that any additional charges, such as escorting a service user to hospital, need to be stated clearly in contracts, statements of terms and conditions as well as in the Statement of Purpose and Service User Guide. The pre-admission assessment process ensures that the needs of prospective residents are identified. Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 11 Discussions with the people who live in the home, staff and the management team, as well as observation, showed that staff were aware of the needs of the residents. The home does not provide intermediate care. Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 12 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): Standards 7, 8, 9 and 10 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. People who live in the home can be confident that they will be treated with respect and that personal and health care needs will be met. Care plans do not provide enough information for staff to know what care is required for each person. EVIDENCE: People who lived in the home said that they were very well looked after by staff and staff were observed treating all the residents with kindness, consideration and respect. Seven personal files were inspected and these contained care plans and risk assessments relating to health and personal care needs that were regularly reviewed. Wherever possible people had signed their own care plans to demonstrate that they had been consulted and were aware of the contents. However all of the care plans did not contain comprehensive, detailed information relating to each person. Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 13 For example, there was health care information contained in one person’s daily notes that was not mentioned in the care plan; another person’s plan did not contain information relating to potential risks to others; and another person’s plan did not contain information about the risks of self harm. For safety reasons, most people who live in the home were not allowed to hold their own cigarette lighters and/or matches and smoking is only permitted outside the building. The Acting Manager confirmed that historical information, including assessments of need and care plans/risk assessments drawn up by health and social care professionals, had been sent to the organisation’s Head Office. Therefore this information was not available for inspection or for staff to look back over someone’s history, should that be required. The care plans were being kept in a filing cabinet in the front hallway of the main house and information from a social care professional said that this cabinet is not always kept locked, therefore anyone can access confidential information relating to residents (see Standard 37). Discussions with the people who live in the home, staff and the Acting Manager, as well as observation, confirmed that personal care is maintained, people can bathe/shower when they choose to and are encouraged to be as independent as possible. Information contained in care plans, discussions with people who live in the home and staff, as well as observation showed that the residents have access to health and social care services such as doctors, district nurses, opticians, chiropodists, dentists, the mental health team and social services. Discussions with the people who lived in the home, as well as staff, confirmed that referrals are made to other relevant professionals when required. Discussion with the residents confirmed that privacy is respected and staff were observed knocking on doors before entering private rooms. The home had a pay ‘phone for people to use but they could also use the home’s ‘phone to make a private telephone call, for which no financial charge was levied. People could also have private telephones installed in their bedrooms at their own expense. Medication was stored securely and a monitored dosage system was used for the majority of medicines. Controlled drugs were stored appropriately and records kept. Staff confirmed that the home has a refrigerator specifically for storing medicines that need to be kept at low temperatures. A staff member demonstrated the procedures for administering medication and all medication received or returned to the pharmacist was recorded. Staff confirmed that no medication was given covertly to any of the people who live in the home. The Deputy Managers said that they carry out regular audits of all the medication in the home and return any unwanted or unused medication to the local pharmacy. Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 14 Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 15 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): Standards 12, 13, 14 and 15 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. The routines in the home are relaxed and relatives and friends can be confident that they are welcomed. Whilst some social activities take place, these are not varied or frequent enough to meet the diverse needs of the people who live in the home. People are not always helped to exercise choice and control over all aspects of their lives. Dietary needs of residents are catered for with a balanced and varied selection of food that meets their tastes and choices. EVIDENCE: Discussions with the people who live in the home, as well as the staff team, confirmed that various individual or group activities take place. The home owns a car to transport people to appointments and social events if required and people are encouraged to use public transport wherever possible. People who live in the home were seen walking in the grounds, either alone or with staff. They also said they have opportunities to go to Launceston or Plymouth to visit the bank, post office or for personal shopping. A few of the residents were participating in a horticultural course, which they said they enjoyed. Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 16 Feedback from a relative confirmed that swimming and horse riding were also available for a few people. One person was seen playing a board game with staff and others were watching television or reading newspapers. On one of the days of inspection, a lay preacher was visiting the home to offer communion to anyone who wanted to participate. Therefore, whilst it was evident that some activities take place for some of the residents, there were also many people who were not involved in any kind of activity, including some people who spent most of the time in their bedrooms. Feedback from two relatives commented on the lack of suitable activities and social contact for some of the older people who live in the home. The home had previously employed an activities co-ordinator but, due to a change in job roles, this post was vacant at the time of inspection. However the Acting Manager confirmed that another activities co-ordinator would be recruited as soon as possible. Discussion with the people who live in the home, as well as information from relatives and the staff confirmed that visitors were actively welcomed into the home and may visit whenever they like. However two relatives said that they would appreciate better communication from the home such as helping people to make telephone calls, being informed of changes in health needs and about what is happening in the home. One relative commented that people had been moved into the main house without any discussion or consultation with either the person concerned or the relatives. This issue was also the subject of a complaint earlier in the year from a representative of another resident. However, discussion with some of the younger people who live in the home, confirmed that they had been consulted and given a choice of bedrooms. Therefore, whilst some people were given the opportunity to exercise choice and control over the move into the main house, this has not been the case for everyone. The people who live in the home said that they liked the meals and can choose what they want. People were asked each day what they would like for their main meal on the next day, which means that people cannot always remember what they ordered. At the previous inspection, the home was providing a daily menu in the dining room to remind people what is on offer for that day, however this practice has lapsed. Meal timings were flexible and the residents said they were able to enjoy their meals in an unrushed and sociable atmosphere. There were limited opportunities for people who live in the home to use the main kitchen due to health and safety reasons, but there were two kitchenettes where people could prepare their own drinks and snacks if they wished to. Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. People who live in the home can be confident that any concerns or complaints will be listened to and addressed. Arrangements for safeguarding residents are not robust enough to ensure that they are protected from any potential risk of harm or abuse. EVIDENCE: The home had a written complaints procedure but this needed updating with the new postal address and telephone number for the Commission for Social Care Inspection. The people who live in the home said that they knew how, and to whom, to make a complaint should they need to. They said that they had confidence in the staff team to resolve any issues as soon as they arise. The Commission for Social Care Inspection has received two complaints about the home since the last inspection. One of these was investigated thoroughly by a senior manager within the organisation. The other complaint was from the representative of one of the residents about people being moved within the home without any prior discussion, consultation and agreement. The Commission for Social Care Inspection carried out an inspection and found that the complaint was justified. Concerns have also been received by Social Services about the ability of the staff team to manage the potential risks posed by people who live in the home either to themselves or to others. Reviews of everyone’s care needs are being carried out by health and social care professionals. Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 18 Supervision records showed that staff were not always confident in managing any physical or verbal aggression displayed by people who live in the home, potentially posing a risk to other people. Care plans did not clearly identify risks of self-harm or potential risks to others (see Standard 7) therefore staff may not have enough information to adequately protect people. Training records of twelve care staff showed that six of them had attended training related to the protection of vulnerable adults. The home’s training programme also showed that more staff were expected to attend this training in the near future. The home had a procedure regarding the safeguarding of vulnerable people but it did not follow the guidance set out by the local multiagency agreement between the local, health and police authorities. Discussions with staff confirmed that they were aware of adult protection procedures. There was a visitor’s book in the front hallway to record dates, times and names of all visitors to the home. Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 19 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): Standards 19, 20, 21, 22, 23, 24, 25 and 26 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. The main house (where all the residents are living) has been refurbished to a high standard and is clean and comfortable. However more attention to detail would provide a better environment for residents. EVIDENCE: The refurbishment of the main house was virtually complete and all the people who live in the home have moved into the main house. There was no call bell system in the home therefore residents were not able to summon staff in an emergency, or to make a request. This has implications for people with reduced mobility who may not be able to find staff quickly should they need them. At the beginning of the inspection, staff had no way of contacting each other to summon assistance but, by the end of period of inspection, the Responsible Individual confirmed that ‘walkie talkies’ had been purchased. Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 20 Observation, as well as feedback from the residents and relatives, showed that the home is kept clean and there were no unpleasant odours. The refurbishment was of a high standard with good quality furnishings, fittings and décor. The organisation had an action plan in place to address all other areas that need refurbishment and redecoration, including the kitchen, dishwashing room and the laundry, therefore any defects in those areas are not itemised in this report. The communal rooms consisted of lounge room and dining rooms on the ground floor and a smaller lounge/activities room on the 1st floor. Both the lounge rooms had small kitchen areas where the people who live in the home could make their own drinks and snacks if they wished to. There was a designated smoking area, with an overhead shelter (but no walls), at the back of the main house. At the time of inspection, twenty-four of the people who lived in the home had their own bedroom and one person lived in a small flat, consisting of a lounge/kitchen, bedroom and bathroom, on the 1st floor of the adjoining annex (previously known as Trelawney). Two people were sharing a bedroom but there was no information to say that those people, their relatives/representatives or any health or social care professional had been involved in the decision for them to share a bedroom. All the bedrooms contain wash hand basins, many have en suite toilets and some also have en suite baths/showers. The bedrooms are located on every floor of the building and there is a shaft lift between the floors in the main house. Bedrooms were individually furnished and contained many personal possessions. At the beginning of the inspection, new wardrobes were being delivered and placed in bedrooms. The bedrooms were all personalised by or for the residents, depending on their wishes. However, at the beginning of the inspection, people were still waiting to have items such as pictures and shelves put on the walls, as well as waiting for lamp shades, waste paper and laundry bins. These issues were addressed over the period of time that the inspection took place. The type and quantity of furniture varied dependant on the wishes and needs of each person. Bedroom doors were fitted with locks however some of these were not suitable as they had key operated locks on both the outside and inside of the doors. This means that, if a key was used to lock the door on the inside, staff were not able to access the room in an emergency, therefore this type of lock is not suitable. The lock on the door of one of the bedrooms did not work properly. None of the bedrooms contained lockable storage space for money, medication or valuables. Bathroom, toilet and bedroom doors were fitted with appropriate locks that can be accessed by staff in an emergency. One of the en suite facilities of a bedroom on the ground floor did not have a window covering over the frosted glass therefore people could see in, particularly at night with the light on. Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 21 The door of another en suite facility did not close properly due to the position of the bed. At the last inspection, a senior manager within the organisation said that a safe method of opening the new double glazed windows, which only open at the top, was being sought from the manufacturers. She also said that staff had been provided with equipment to reach the windows to ensure that the safety of the residents and staff was not compromised. However, during this inspection, it was found that these windows were still impossible to open without standing on something and it was clear, through observation, that staff were standing on inappropriate items, such as pieces of furniture, to open windows in the residents’ bedrooms. There has been a problem with the telephones for some time, as new cables need to be laid by the telephone company. Due to the location of the home there is a problem with reception for mobile/portable telephones in some parts of the building. The management team confirmed that an appropriate telephone system is being sought that will meet the needs of both the people who live in the home and the staff. Kitchen and laundry facilities were satisfactory at the time of inspection as they are included in the refurbishment plan. The previous inspection found that a bell had been installed in the laundry room so that staff could summon assistance should they need to, but this was not seen during this inspection. Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 22 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): Standards 27, 28, 29 and 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. The management and staff team strive to provide a stimulating, safe environment where people are respected. Recruitment practices are not robust enough to protect the people who live in the home from risk of harm. EVIDENCE: Discussions with the people who live in the home and staff, as well as observation, confirmed that the staff team were respectful, polite, attentive and responsive to peoples’ needs. The staff members on duty were aware of service users’ needs and how to support them. Feedback from relatives said that people generally seemed happy living in the home and that the staff did a good job. Survey forms completed by three relatives made positive comments about the staff such as “the care staff I have dealt with are very good at what they are doing”; and that staff are “friendly and helpful to me” and “very caring”. Two relatives also commented that communication with staff at the home had improved recently. There have been some changes in the management and staff team since January 2008, resulting in changes to staffing levels. An Acting Manager and two Deputy Managers have recently been appointed and they were looking to recruit another activities co-ordinator. Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 23 Discussions with the people who live in the home, the staff on duty and the Acting Manager confirmed that there was usually enough care staff on duty to meet the needs of the residents. There were four care staff on duty in the mornings and three in the afternoon and evening until 11pm. However, staff did not have much time to spend with the residents and a relative commented on this. Two relatives also commented on the lack of suitable activities and trips out, which are also affected by staffing levels. There were only two staff on duty at night for twenty-seven residents and this was not enough considering that bedrooms are on three floors of the building and there was no call bell system for residents to use should they need to ask for staff assistance. Following discussion with the Acting Manager, it was agreed that staffing at night would be increased by at least one more person as soon as possible. Catering, laundry, domestic, maintenance and administrative staff supported the care staff. Discussion with the Acting Manager, as well as staff training records, confirmed that training had lapsed since the last inspection. However, a new training programme has been set up and courses booked so that all staff can participate in training on adult protection, health and safety, first aid, manual handling, fire safety, food hygiene, infection control, control of hazardous substances, mental health awareness and challenging behaviour. Training records of twelve staff members showed that five of them have achieved a relevant care qualification that is either a National Vocational Qualification (NVQ), at level 2 or 3, or the equivalent. Designated staff undertake medication training and all staff were supervised on a regular basis. The staff file of a recently recruited staff member was inspected and contained information to show that all the required checks and references had been obtained prior to employment. The Acting Manager confirmed that she had examined all the files of staff who have been recruited over the last two years or so and found that people recruited from abroad had not had checks carried out through the Criminal Records Bureau because they had been recruited through an agency. Therefore she was in the process of having these checks done. Inspection of all the staff files showed that some of these staff had not been asked to provide references and reasons for any gaps in the employment history of staff had not been documented. Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 24 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): Standards 31, 33, 35, 36, 37 and 38 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. The Acting Manager has a good understanding of the areas in which the home needs to improve and is supported well by the senior staff. The quality of care provided to the people who live in the home is not being properly monitored. EVIDENCE: The home did not have a manager registered with the Commission for Social Care Inspection at the time of the inspection. Since the Registered Manager left in December 2007 there have been changes in the management team. At the time of inspection, the organisation’s Human Resources manager had been appointed as Acting Manager, supported by the home’s Responsible Individual. Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 25 Discussion with the people who live in the home and the Acting Manager, as well as records, confirmed that most people or their relatives/representatives managed their financial affairs. The home did manage small amounts of spending money on behalf of some of the residents. Records of the money for four of the residents were inspected and were generally well kept although there was a minor discrepancy, which one of the Deputy Managers agreed to resolve immediately. The Acting Manager confirmed that historical information, including assessments of need and care plans/risk assessments drawn up by health and social care professionals, had been sent to the organisation’s Head Office. Therefore this information was not available for inspection or for staff to look back over someone’s history, should that be required. The care plans were being kept in a filing cabinet in the front hallway of the main house and information from a social care professional said that this cabinet was not always kept locked, therefore anyone could access confidential information relating to residents. Accidents and incidents were documented at the time of the event. These were monitored by the Acting Manager to establish whether any patterns emerged and to decide whether other health and social services professionals needed to be involved to provide advice, guidance or assistance. Documentation in the home confirmed that safety checks have been carried out including portable electrical appliances, hoists and the shaft lift. Hazardous substances were locked away safely. The new training programme confirmed that all staff will be expected to undertake training in health and safety, fire safety, first aid, food hygiene, infection control, control of hazardous substances and manual handling. Inspection of the fire logbook showed that the required weekly and monthly tests/checks of the fire alarm system/equipment were carried out. The home had coded door locks but these were not connected to the fire alarm system so did not open automatically when the fire alarm was activated. A member of the management team confirmed that the home’s fire safety contractor would be carrying out this work during the week commencing 14th April 2008. A fire door on the 1st floor of the main house did not close properly and did not have a handle to open it easily. Discussion with staff, as well as training records, showed that staff had not received any fire safety training in recent months. However some staff had attended a fire drill in March 2008 and others had completed a computerised test on fire safety awareness. There was no evidence to show that staff whose first language was not English were aware of fire safety procedures. The Acting Manager confirmed that all staff would receive training in fire safety awareness by the end of May 2008. During the inspection, the door to the laundry room was found wedged open and the door on the stairwell leading down to the laundry room had been tied open, but these doors were closed immediately by staff. Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 26 All the radiators in the main house had low temperature surfaces, thereby reducing the risk of residents being burned by hot radiators. The Acting Manager confirmed that all hot water outlets accessible by the residents were thermostatically controlled to ensure that hot water was kept to a temperature where people would not be scalded. All the windows above ground floor level that were inspected were restricted so that they could only be opened a small way, thereby preventing residents from falling out of them. The Acting Manager also confirmed that restrictors were fitted to all windows above the ground floor. Whilst the home does have a quality assurance system in place, it was evident that this was not being used properly. Also, a member of the organisation’s management team used to visit the home regularly and, once a month, provide a written report on the conduct of the care home to the Registered Manager and to the Commission for Social Care Inspection. However, these visits were not taking place and no reports had been written. If these processes had been in place, the issues identified during this inspection would have already been identified and dealt with by the organisation. Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 27 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 1 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 2 2 3 2 3 3 STAFFING Standard No Score 27 1 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 3 2 2 Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement The Registered Person must compile an up-to-date statement of purpose. A copy must be provided to the Commission for Social Care Inspection and, on request, to the people who live in the home or their representatives. This is so that prospective residents have the information they need to make an informed choice about where to live. The Registered Person must produce an up-to-date service user’s guide for current and prospective residents. This is so that everyone who lives in the home, or is considering living in the home, knows what facilities and services are available to him or her. Care plans must contain comprehensive, detailed information about the care needed by residents. Risk assessments must clearly detail the risks people may experience either because of health care needs, risks they may pose towards others and DS0000044111.V361662.R01.S.doc Timescale for action 16/06/08 2. OP1 5 16/06/08 3. OP7 15 16/06/08 Priory Manor [formerly Trebursye Manor] Version 5.2 Page 29 4. OP18 13(6) 5. OP27 18(1)(a) 6. OP27 18(1)(a) 7. OP29 19 risks of self-harm. This is to ensure that staff know what care they are to provide, in what way it is to be provided, and to achieve consistency between different staff members. The Registered Provider must make arrangements to prevent the people who live in the home from being placed at risk of harm or abuse by: • Ensuring that all staff receive training, and feel confident, in managing situations of verbal and physical aggression • Carrying out comprehensive and detailed risk assessments for each resident • Amending the procedure for safeguarding people to reflect the local multiagency procedure to ensure that every incident is reported promptly and investigations are managed appropriately. The number of staff on duty at night must be increased to ensure that the needs of people who live in the home are met and that people are protected from any possible risks to their health, safety and wellbeing. The Registered Provider must review the staffing levels at all times of the day and night. This is to make sure that there are enough staff on duty to meet the health and social care needs of people who live in the home, and that people are protected from any possible risks to their health, safety and wellbeing. The Registered Provider must ensure that recruitment procedures are sufficiently DS0000044111.V361662.R01.S.doc 14/07/08 16/06/08 14/07/08 14/07/08 Priory Manor [formerly Trebursye Manor] Version 5.2 Page 30 8. OP33 24 9. OP33 26 10. OP37 17(4) 11. OP38 13(4) robust to protect people who live in the home from risk of harm by: • Obtaining a Criminal Records Bureau check for all staff members • Obtaining two written references for all staff members • Exploring and documenting the reasons for any gaps in the employment history of staff members. This is the second inspection where a requirement relating to recruitment practices has been made. The Registered Provider must reinstate the quality assurance system to review and improve the quality of care provided. This system must include consultation with residents and their representatives. A report must be produced and made available to residents, with a copy supplied to the Commission for Social Care Inspection. This is so that the management of the home can measure how well the home is achieving goals for people who live in the home. The Registered Provider must reinstate the monthly visits to monitor the conduct of the care home. This system must include consultation with residents and staff. Records pertaining to residents must be held in the home for at least three years after the date of the last entry. This is so that staff in the home can access a person’s history and the records are available for inspection, if required. The Registered Provider must ensure that fire safety DS0000044111.V361662.R01.S.doc 14/07/08 14/07/08 14/07/08 16/06/08 Priory Manor [formerly Trebursye Manor] Version 5.2 Page 31 precautions are followed and that staff understand and can implement fire procedures. This is so that residents are protected from the risk of fire and staff know what to do in the event of a fire. 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 OP12 Good Practice Recommendations Social and community activities should be more varied, interesting and innovative to match the residents’ preferences and satisfy their social, cultural, religious and recreational interests. The Registered Provider should ensure that, where requested, people who live in the home are assisted with making telephone calls to relatives, and relatives are informed about changes in health needs and about events/activities taking place in the home. The type of information to be shared with relatives should be agreed when a person is admitted to the home and documented within the person’s care plan. This is to ensure that relatives/representatives are kept up to date with changes to a person’s needs, as well as what is happening in the home. Communication should be improved between the management in the home and the relatives and representatives of people who live in the home. This is to ensure that relatives/representatives are kept fully informed of any changes in the care needs of the residents and that proper consultation takes place about their future needs. People who live in the home should be helped to exercise choice and control over all aspects of their lives. No changes to a person’s life, such as moving or sharing bedrooms, should take place without proper consultation and agreement with the person concerned and relatives/representatives if appropriate. Evidence of this consultation should be documented. DS0000044111.V361662.R01.S.doc Version 5.2 Page 32 2. OP13 3. OP13 4. OP14 Priory Manor [formerly Trebursye Manor] 5. 6. OP15 OP16 7. OP18 8. OP22 9. 10. 11. OP21 OP21 OP24 12. OP24 13. 14. OP26 OP28 15. OP37 A menu for each day should be available to remind people what meals are on offer for that day. The complaints procedure should be updated with the new postal address and telephone number for the Commission for Social Care Inspection. This is so that people who live in the home, and their relatives/representatives, know how to contact the CSCI should they need to. All staff should attend the safeguarding (alerter’s) training provided by the Local Authority. This is to ensure that staff are aware of local procedures to follow should an untoward incident occur. The Registered Provider should consider installing a call system with an accessible alarm facility in the home so that residents and staff can summon assistance if they need it. The window of the en suite facility in Room 28 should be suitably covered to provide the person in that room with more privacy. Arrangements should be made to ensure that the door of the en suite facility in Room 21 closes properly to provide the person in that room with more privacy. Bedroom doors should be fitted with locks that are suited to the capabilities of individual people and accessible to staff in an emergency. The lock on Room 5 should be repaired or replaced. This is so that the people who live in the home can lock their bedroom door should they wish to, for reasons of privacy and to keep out unwanted visitors, but staff can get in if they need to. Each person should be given a key to his or her own bedroom door, unless a risk assessment suggests otherwise. All of the bedrooms should have lockable storage space so that there is somewhere for people to keep money, medication or valuables safely secured. Each person should be given a key, which s/he can retain, unless a risk assessment suggests otherwise. A system should be provided in the laundry so that staff can summon assistance if they need to. At least 50 of the care staff should have a care qualification to at least a level 2 National Vocational Qualification (NVQ). This is so that staff are trained and competent to care for the people who live in the home. Confidential information pertaining to the people who live in the home, such as care plans, should be kept in a secure place all times. This is to ensure confidentiality is maintained and so that only those people who are authorised can have access to the information. Priory Manor [formerly Trebursye Manor] DS0000044111.V361662.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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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