Inspection on 02/11/05 for Priory (The)

This inspection was carried out on 2nd November 2005.

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

The inspector 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 (The) 15/05/06

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 2nd November 2005 09:30 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.V263378.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Priory (The) DS0000058301.V263378.R01.S.doc Version 5.0 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.V263378.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd May 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 to those who may have dementia. There are two floors and access to the first floor is by stairs only. 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. Priory (The) DS0000058301.V263378.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 7 hours on 2nd November 2005. The manager was met with and the inspector spoke to two visitors, six service users and three staff members. The following areas were looked at; care plans and risk assessments, assessment and admission documents, medication and medication records and staff training and recruitment records. What the service does well: What has improved since the last inspection? What they could do better: There are some elements of record keeping in medication and risk assessments, which could improve, that would benefit service users. The care is being provided well, but the accompanying records do not reflect all of the care that is being provided. This is especially true for service users who have rapidly changing needs and those who self medicate. Priory (The) DS0000058301.V263378.R01.S.doc Version 5.0 Page 6 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.V263378.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Priory (The) DS0000058301.V263378.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Standard 6 does not apply to this home. Service users benefit from a comprehensive assessment that assures their needs can be met. EVIDENCE: The records for a new service user were seen and the service user was spoken with. There is an assessment record with details of the service user’s history and their needs, likes and dislikes. Information is gathered from various sources, including family and assessments carried out by other health or social care professionals. This provides details prior to admission. The service user did not choose the care home, but relied upon the opinions of their family. The service user commented that the home seemed very nice. A short term care plan had been written to ensure that the service user’s needs were being met. New service users have choice over whether they want to stay in the home, as a review meeting is held after one month. Priory (The) DS0000058301.V263378.R01.S.doc Version 5.0 Page 9 Priory (The) DS0000058301.V263378.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8, 9 Standards 7 and 10 were assessed as met at the last inspection. Service users may be at some risk from a lack of documentation about their care needs. Elements of poor medication recording may put service users at risk. EVIDENCE: Three service users’ care plans were seen. These varied as some had short term care plans written in a different format to the standex care plans in place. The manager discussed plans to change the style of care plans so they can be more flexible. Long and short term care plans are written, identifying the needs and how they are to be met. There was some evidence that changes had been responded to and the care plan adjusted accordingly. Where service users have particular needs, community nurses provide the healthcare they need. Staff discussed the level of care that they are providing, which is high and very precise, however, this was not fully documented. Some elements of service users’ healthcare needs had not been fully identified on the care plan or on their risk assessment. A specific example was discussed with the manager, Priory (The) DS0000058301.V263378.R01.S.doc Version 5.0 Page 11 where the care provided to a service user was greater than what was documented. Service users commented on how they felt all aspects of their care needs were met and those views were also shared by the visitors spoken with, who were particularly pleased with the return to good health for their relative. Medication records showed that staff are not recording when medication is not being given. A previous requirement about codes needing to be used when medication is not given had not been met. The pharmacy inspector for the CSCI will visit the home to offer guidance and advice. It is not clear on the medication administration sheet when service user’s self medicate. Some of this information was changed during the inspection, so that accurate records were in place. Medication administration sheets are used to record medication received in the home and there is a record in place for recording controlled medication. On occasion, handwritten entries are being written on the medication administration sheet and this needs to be signed by two staff if they have not been written in by a GP. No dates were recorded of when staff open creams and ointments. Staff are receiving medication administration training through a distance learning course with support from a local college. Priory (The) DS0000058301.V263378.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14 Standard 12 was assessed as met at the last inspection and standard 15 was exceeded at the last inspection. Service users benefit from interesting and varied activities, trips out and interaction with families and friends. EVIDENCE: Two visitors were met with during the inspection. They spoke about the care of their relative and how supportive the Priory had been in enabling the service user to return to good health after a period of illness. They spoke about a quarterly newsletter for relatives, which details up and coming events that they can be involved in. They commented on the range of trips out and that this seems to have increased. They were pleased with the manager, owners and the staff team who work at the home. Service users had enjoyed trips to garden centres and country parks, as well as activities in the home. A bonfire was being built in the garden for Bonfire night with fireworks. There has been a summer fete and a coffee morning to raise money for a local charity. The manager discussed plans to start a reminiscence table with objects from the past that could be handled, so as to promote conversation. Service users told the inspector that there was always someone to talk to in the lounge and several service users enjoyed the company of friends they had Priory (The) DS0000058301.V263378.R01.S.doc Version 5.0 Page 13 in the home. During the morning, staff were observed to sit and talk to service users, discussing the news and doing manicures. Service users said they could choose want they wanted to do and also commented on the choice they have over meals, which everyone praised as being very good. Priory (The) DS0000058301.V263378.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Both these standards were assessed as met at the last inspection. EVIDENCE: Priory (The) DS0000058301.V263378.R01.S.doc Version 5.0 Page 15 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 Service users benefit from a comfortable home where they feel at ease. EVIDENCE: There have been some changes made to the garden. Small wrought iron gates and fencing have been placed around the edge of the lawn with a special lock in order to help keep service users safe. There are plans to make part of the dining room an area for craft activities, which are enjoyed by many service users. The condition of the walls by the laundry room and toilets outside the dining room should be looked at as some cracks are appearing in the plaster. There are plans to install a chairlift in the rear staircase. Service users feel that the quality of the accommodation is very good and enjoy the space in their bedrooms and the opportunity to personalise them with items brought from home. On the day of inspection a leak in the laundry was being dealt with. The home was clean and tidy. Priory (The) DS0000058301.V263378.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were assessed as met at the last inspection. EVIDENCE: Records for one staff appointed since the last inspection were seen. All records relating to safe recruitment practice were in place. Priory (The) DS0000058301.V263378.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 38 Quality assurance standards have not been assessed for this year yet, so a judgement cannot be reached. Service users’ finances are not managed by the home. Service users may have their safety compromised by a lack of risk assessment about first floor windows and radiators. EVIDENCE: The owner plans to complete a quality assurance survey after Christmas 2005. This is because the new manager has only been in post since April 2005. A previous survey took place in December 2004. The views of families and stakeholders will be sought and a report needs to be sent to the CSCI on completion of the survey. None of the service users hold finances in the home. Any money they have is managed independently by families or other advocates. Any money they Priory (The) DS0000058301.V263378.R01.S.doc Version 5.0 Page 18 require is provided by the home out of petty cash and then costs are billed to the families or advocates. First floor windows were seen not to have restrictors fitted. The inspector discussed recent re- issued guidance on the need for first floor windows to have restrictors fitted. In the meantime, risk assessments must be completed. Radiators are in the process of being covered. This was raised at the last inspection and was discussed with the owner following this inspection. The date for them to be completed had passed, but the owner assured the inspector that they would be covered by the end of the year. Priory (The) DS0000058301.V263378.R01.S.doc Version 5.0 Page 19 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 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Priory (The) DS0000058301.V263378.R01.S.doc Version 5.0 Page 20 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 OP8 Regulation 13(4)(a) Requirement Radiators must be individually risk assessed with an action plan that shows when they will be covered. (Carried forward from last inspection. Met in part) Care plans must reflect all the care and ways that care is being provided. Staff must receive medication training. Staff must have their competence assessed after they have received training.(Staff are currently doing this training) Medication records must be kept accurately by staff. Staff must use the correct code when medication has not been administered and record this code on the correct date. (Carried forward from the last inspection) First floor windows must be risk assessed relating to individual service users and generically. An action plan must be drawn up to show when windows will have restrictors fitted. Timescale for action 31/01/06 2. 3. OP8 OP9 15(b)12 (1)ab(2) (3) 13(2) 30/12/05 31/01/06 4. OP9 13(2) 30/12/05 5. OP38 13(4)ac 30/12/05 Priory (The) DS0000058301.V263378.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP9 OP9 OP23 Good Practice Recommendations Staff should record the date on creams and ointments when they are opened. When changes to medication needs to be handwritten onto a MAR sheet, two staff should sign the entry to verify the instructions and the dose. The wall close to the laundry and dining room should be examined and repaired. Priory (The) DS0000058301.V263378.R01.S.doc Version 5.0 Page 22 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.V263378.R01.S.doc Version 5.0 Page 23 - 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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