Inspection on 15/05/06 for Priory (The)

This inspection was carried out on 15th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 (The) 02/11/05

Priory (The) 23/05/05

Priory (The) 18/11/04

Priory (The) 20/04/04

Similar services:

Manor Lodge

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE Priory (The) Greenway Lane Chippenham Wiltshire SN15 1AA Lead Inspector Mrs Jacqui Burvill Unannounced Inspection 15th May 2006 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 (The) DS0000058301.V289452.R01.S.doc Version 5.1 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 (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Priory (The) Address Greenway Lane Chippenham Wiltshire SN15 1AA 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) 01249 652153 Lower Green Ltd Mrs Julie Grimshaw Care Home 18 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (18) of places Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd November 2005 Brief Description of the Service: The Priory is a detached property set in its own grounds, close to Chippenham town centre. Service users have their own rooms, many of which have ensuite facilities. The home offers care and accommodation to service users who are over the age of 65 years and including those who may have dementia. There are two floors and access to the first floor is by stairs and a stair lift on the rear staircase. Bedrooms are on the ground floor and the first floor. There is a communal dining room and sitting room and two assisted bathrooms. There is level access to the front of the home. In addition to the full time manager, there are at least three staff on duty during the morning, with two staff on duty during the afternoon and evening. At night, there is one sleep in staff member and one waking night staff member on duty. Fees range from £475 to £500 per week. Inspection reports are readily available in the home and the owner also writes a newsletter for service users and their relatives updating them on the current care issues. Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The pre inspection field work involved the owner and manager completing a pre inspection questionnaire. Following this, questionnaires were sent to service users or their relatives. 13 surveys were sent in total and 12 surveys were returned. There was one letter returned in place of a completed survey. The response from the survey was exceptional. 6 out of 12 surveys said that service users always received the care and support they needed with a further 6 out of 12 saying they usually received this. 7 out of 12 surveys said that staff were available when needed, 7 out of 12 surveys knew how to make a complaint, and there were additional comments made, that relatives and service users did not envisage any times where they would need to complain. 11 out of 12 surveys said that the home was clean and fresh. There were a number of positive comments about the cleanliness and decoration of the home. Additional comments made included; ‘The Priory is definitely the next best thing to one’s own home’. ‘If all elderly people could go to The Priory, old age would not be a bad thing, especially since the new manager arrived, adding her personal touches to the place.’ ‘I am very happy living at The Priory’ ‘ Very homely atmosphere, they try to make us feel part of a family’ ‘My relative is very happy at The Priory and her health has improved, staff are always kind and cheerful’. ‘The home is clean, fresh and well decorated.’ The owner provided copies of three recent newsletters before the inspection took place. These showed a range of social activities both inside and outside of the home that are extended to families. The whole approach appears to be to include families as much as possible and they seem to appreciate and value this approach. The owner also provided a list of all of the improvements that have taken place at The Priory over Autumn and Spring 2005 – 06. This included new equipment, new bedding as well as re-decoration of 7 bedrooms and the installation of a new ensuite. The visit to the home took place over two days, unannounced on the 15th and announced on 19th May 2006. There was a tour of the premises and the following records were looked at; assessment and admission, care plans and risk assessments, staff training and recruitment, medication, menus, some policies and procedures, fire safety and other health and safety records. The lunch on 15th May was sampled and three staff, five service users and two Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 6 visitors were spoken with. There were also discussions with the manager and the owner. What the service does well: What has improved since the last inspection? There have been continuing development and improvements in the service. One aspect of this is the range of trips into the nearby cities and surrounding countryside. Service users appreciate these trips. Great care is taken over the choice of venues by the manager, who ensures that they will be accessible to service users and will meet their needs. The manager has introduced a new style care plan, which is easier to read and understand. The list of improvements to the premises is lengthy and includes stair visibility improvements, the installation of a stair lift on the rear staircase and new seating and garden furniture for the garden. Musical activities have increased in the home, this includes outside entertainers and more musical instruments for service users, along with the introduction of music therapy. New games have also been bought for their use. A separate record is maintained for recording these details. The manager has completed her Registered Manager’s Award. Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 7 Team meetings have been enhanced by further training in unusual yet relevant topics, such as aromatherapy, a talk by the Blind Association and the role and function of a funeral director. Medication administration has been improved, with staff wearing reflective jackets with a warning sign on the reverse indicating they are administering medication and are not to be disturbed. All of the requirements and recommendations have been met 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. Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Standard 6 does not apply. Service users benefit from a detailed assessment of their needs and a trial period in the home. An initial care plan is in place on the day of admission. There are consultations with other health or social care professionals and the families. EVIDENCE: The records for one recently admitted service user were looked at. The service user was met with and a relative, who said the care at The Priory, was ‘excellent’. Relatives are provided with a copy of the statement of purpose and the service user guide, and this is discussed at admission. Relatives hold these documents on behalf of service users. They sign to say they have received it and a resident checklist specifies who has it. Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 10 At the initial enquiry, a brochure is sent out with an introduction to The Priory. If the application proceeds, then an assessment takes place. The contract is discussed and after the assessment and admission, there is a trial period of four weeks. The manager completes the assessment when the service user is at their previous placement. This lists activities and a description of their possible strengths and needs. A score is made and notes alongside are completed, which leads to a care plan. Each section is signed and dated. Other details are gathered, such as a personal profile, where the history of the service user’s life is described with input from the family. Following the assessment, an initial care plan is written, identifying medical history needs, daily living needs, as well as personal care, mobility, managing finances and diet. A copy of this is held in the service user’s own room. Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area was excellent. This judgement has been made from evidence gathered both during and before the visit to this service. Service users have their own copy of the care plan and are aware of their own needs and how they are to be met. Health care needs are fully met, with regular and positive consultation with health care professionals and relatives. Medical needs are carefully monitored and responded to at the earliest possible stage. Some service users are partly responsible for their own medication, which is carefully monitored. Medication is carefully administered, so as to ensure service users safety and well being. Service users benefit from being treated with dignity and respect by staff at all times. Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 12 EVIDENCE: Three service users’ care plans were looked at. Two of the service users were spoken with and one of the relatives. Additional documents, such as risk assessments and daily notes were read. One relative spoken with said she had not had a day’s worry since her relative had been admitted. Each service user has a shortened version of their care plan in their own room. One service user described how staff read the care plan to her regularly due to her needs and how delighted she was with this. The service user knew exactly what her care needs were and how they were to be met. Likes and dislikes were clearly described too. The plans looked at were accurate in detail and provided a good description of needs and how they are to be met. The manager has introduced a new format, which identifies needs and actions to be taken. Care plans showed evidence that they had been reviewed monthly. There is a section in the care plan describing any health needs and any action taken by a health care professional, or by the staff team. This includes catheter care and visits by community psychiatric nurses. GPs visit the home on request and service users may have to change GPs due to the change in location from their previous home. Service users spoken with were happy about this change. Details of blood tests and changes to medication are faxed directly to the home. There is a monitored dose medication system in the home, which is provided monthly. The manager discussed some of the issues that have arisen with the company that provides the medication, which she is addressing. Medication administration sheets show the dose and the amount given. Where entries have been handwritten, these have been countersigned by two staff. There are clear records showing what medication has been received and returned. Some service users partly self medicate. There are risk assessments in place, a description in the care plan. Service users have safe lockable storage in which to keep their medication. Each pack of medication and the medication administration sheet has a photograph of the service user on it. This also corresponds with the care plan, which also has the same photo of the service user. Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 13 Staff were observed during part of a medication round. Staff wear a fluorescent jacket over their uniform with a warning sign stating that they are not to be disturbed whilst administering medication. Service users were observed to be treated with dignity and respect at all times. Staff knock on the bedroom doors and wait for an answer. Some service users have private phone lines in their room, to enable them to keep in regular contact with their families. Post is delivered directly to the service users. Issues regarding privacy and dignity have been discussed on induction and in a recent training course on managing aspects of bereavement. Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 14 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, 13, 14, 15 Quality in this outcome area was excellent. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from a lifestyle which includes regular consultation over their choices of activities and meals and regular visits and involvement with their families. EVIDENCE: Service users and relatives spoke about how they felt The Priory met their needs, expectations and preferences. One relative described how, on arriving to view The Priory, she immediately realised it was the right atmosphere for her relative with the style of furnishings, the number of service users who live there and the atmosphere amongst the staff team and service user group. Service users are able to bring items with them from home, so that their room reflects their choices and preferences. Service users are encouraged to manage as much for themselves as they would like to, and many service users have a leisurely start to the day, with breakfast served in their bedroom. There are religious services in the home, as well as in the local community. Staff provide a variety of seasonal activities Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 15 and showed the inspector the range of very creative Easter Bonnets that had been made. There is a separate activity record, divided into sections such as arts and crafts, games, walks and outings. These outings have included a trip to Bath Abbey and the Pump Rooms for lunch, as well as individual trips to garden centres. The inspector observed a game of dominoes arranged by a staff member, involving five service users and a relative. Music and exercises are a regular occurrence, with outside entertainers coming to the home and musical instruments in use with the manager and staff leading musical sessions. Service users with special interests are encouraged to develop and maintain these. There is a library service on offer in the home, including talking books. Although there are no formal service users’ meetings, the manager speaks to the service users at least weekly and usually more often, discussing future events and thoughts they may have about the home. None of these talks had been recorded and the manager plans to do this in future. By the time the second visit took place, a record book had been made and there was already one entry. One service user had asked if it was possible to have a swimming pool. Relatives are welcome in the home and there is a family atmosphere, where relatives are kept up to date about changing needs, and also included in events in the home. There are positive links between the home and the families, through newsletters and meetings. Service users’ finances are not dealt with by the home. This is explained during the assessment period. Families act as appointees. The main meal of the day was sampled. There were two choices and one service user had a specially prepared dish as an alternative. The inspector observed staff asking service users the day before about the meal and any alternative they would like. A great deal of time and care was taken when doing this. Meals are cooked from fresh and wholesome ingredients. Service users were observed to enjoy their meal and a second serving was also available. Dessert and tea and coffee were served. The meal was appetising and well presented. The dining room is set with small tables for up to four service users and laid with linen, flowers and the menu of the day. Cold drinks are readily available in the lounge for service users to help themselves to, as well as hot drinks regularly provided by staff. Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 16 Records are maintained for all meals. There is a five week menu plan, which is changed and adapted over a year. At this time, there are no special diets catered for. The kitchen was exceptionally clean and tidy. Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users best interests are protected by a clear view of their rights and the home’s responsibility to meet these, and a robust complaints procedure. Service users are protected from abuse by staff knowledge and awareness. This would be further enhanced by amending the procedure in light of current guidance. EVIDENCE: No complaints have been received by the home or the CSCI. There is a complaints policy and procedure, which is reviewed annually. There is also a document called ‘Our Commitment to You’, which sets out the way in which The Priory staff and management team ensure that service users rights and choices are met. Each service user has a copy of this commitment in their own room. The Priory welcomes complaints as an opportunity to develop and learn. Comments received from the service user survey indicates that they have found no reason to make a complaint in this home. There are abuse and adult protection procedures in place. Close examination of these showed that the procedure specifies who to report to as isolated units, Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 18 rather than as a multi disciplinary approach. The up to date copy of the Wiltshire and Swindon ‘No Secrets’ procedure was left in the home, by the inspector, as well as information about the Wiltshire adult protection workshops. The management team and the inspector discussed the home’s current policy, which may need to be reviewed in light of information and guidance received as part of the workshop. There have been no referrals to the adult protection team since the last inspection. The manager is clear about what needs to be reported, as are staff, but no incidents have occurred that needed reporting. Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from a safe, attractive and well maintained home, that is clean, fresh and hygienic. EVIDENCE: The Priory is a detached house, set in its own grounds close to Chippenham town centre and a nearby park. There was a tour of the premises, including some service users’ bedrooms, all communal areas, bathrooms and the laundry room. Service users’ bedrooms are on the ground and first floor. There is a stair lift installed, with instructions for its use alongside. Service users are encouraged to use the stairs for as long as they feel able to do so. Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 20 Bedrooms have ensuite bathrooms and service users spoken to all commented on how this enabled them to feel their privacy and dignity were respected. Bedrooms are comfortable and service users have been able to bring personal possessions, or other items of their choice. Bedrooms are spacious and there is sufficient space for visitors to sit. Some service users have their own private phone line and a lockable space in their room. There are two communal bathrooms, one on each floor. The water was tested by hand and found to be hotter than expected. The thermometer used to test the water was not found immediately, as it was outside. This was discussed with the manager and the book that records water temperatures could not be found during the inspection. However, the inspector was informed that staff test the water before service users have a bath. Outlets in all bedrooms are also checked. Although there was no immediate risk to service users, the water temperature may need to be regulated again. There has been a programme of covering the radiators which is now completed and window restrictors have been fitted. The home is attractively and comfortably decorated, and there is a constant programme of improvements and maintenance. The garden is a pleasant area for service users to sit outside and there is level access to the seating areas. The laundry was in use at the time of inspection and was well ordered and clean. Equipment in use meets infection control guidelines. The home was very fresh, clean and tidy on the day of inspection and there were no offensive odours in the home. Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 21 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, 28, 29, 30 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users’ needs are met by a competent and consistent team of staff, who are appropriately trained to meet their needs and who have been recruited in a safe, robust manner. EVIDENCE: On the unannounced day of inspection, there were three staff on duty in the morning and two on the afternoon and evening. Additional staff were on duty as cook and cleaner. There is one waking night staff and one sleep in staff every night. The rota shows that this is the usual pattern of staff in the home. The manager is supernumerary to the rota. No agency staff are employed in the home. 50 of the staff have achieved National Vocational Qualification certificates. Four staff have NVQ level 3 certificates and one staff member is also currently doing NVQ level 3, whilst another two staff are doing NVQ level 2. The records relating to five staff were seen. Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 22 Initial details are obtained over the phone from new applicants, who are then sent an application form. This is received prior to the interview. Criminal Record Bureau checks are discussed during the interview, when arrangements are made with successful applicants to begin processing the check before they are employed. Protection Of Vulnerable Adult First checks are completed only in an emergency, when staff need to be recruited urgently. Two references are obtained. Staff have a contract and terms and conditions once employment has been confirmed. Staff are also provided with a copy of the General Social Care Council’s code of conduct. There is a strong commitment to training in The Priory. Monthly team meetings include a section on in house training. Sessions have included updates on medication monitored dosage systems, averting crisis in palliative care, the role of a funeral director and a talk by the Blind Association. These training sessions have been arranged in response to staff need for knowledge and guidance. Future training is planned in adult protection, aging skin, continence, tissue viability, first aid, basic food hygiene and dementia. A member of staff with a first aid certificate is on duty at all times. Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from a manager and owner who have high standards of care and who discharge their responsibilities fully and ensure the home is run in the best interests of the service users. Service users’ health, safety and well being are promoted and protected. EVIDENCE: The registered manager has over twenty two years experience, having previously run her own care home for over 3 years. She has completed the Registered Manager’s Award, has a nursing qualification and is now embarking on a mentoring course. Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 24 Recently, a quality assurance report has been recently received by the CSCI. The surveys showed a positive response and suggestions put forward by the service users and relatives were included in a plan. Quality assurance will be assessed again next year. The home has tried to elicit responses form community healthcare professionals, but had a poor response from this. As a result, the questionnaire may be adapted. Regulation 26 visits which are unannounced visits made by the owner will now take place and formats have been shared with the owner, who confirmed his intention to use the shorter version and include monthly innovations. The home does not manage service users finances. Service users hold their own money in small amounts. Some relatives leave the actual amount required for a specific purpose and a receipt is provided for the relative. Safes are provided in service users’ rooms. Fire safety records were looked at. All staff have received fire safety training in April and June 2006. The actual date of the session should be recorded above the staff initials. All of the fire safety checks were in order. The accident book is used appropriately and provides information on service users who may be at risk of falling. There have been no serious falls or accidents in the home. Risk assessments were all up to date and in order. These include visits out into the community. COSHH safety data sheets were in place for products in use in the home. Staff have also received health and safety training. The Infection Control manual is in place and has been used by the manager as a valuable reference guide. Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 25 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 4 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X N/A X X 3 Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 26 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP7 OP18 OP19 OP38 Good Practice Recommendations Daily notes should record more detail about the care that has been provided. The adult protection policy and procedure should be amended to reflect the multidisciplinary approach. Water temperatures should not be greater than 43 degrees Celsius in bathrooms and service users’ bedrooms. When staff receive fire safety training in house, the actual date of the training session should be recorded above their initials. Priory (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 (The) DS0000058301.V289452.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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