Inspection on 23/05/05 for Priory (The)

This inspection was carried out on 23rd May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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) 15/05/06

Priory (The) 02/11/05

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 2BB Lead Inspector Jacqui Burvill Announced 23 May 2005 rd 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 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) D51_D01_S58301_PRIORY_V21997_230505_Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Priory (The) Address Greenway Lane Chippenham Wiltshire SN15 1AA 01249 652153 01249 464832 mballworth@tinyworld.co.uk Lower Green Ltd. Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Julie Grimshaw -yet to be registered Care Home 18 Category(ies) of 18 DE(E) Dementia - over 65 registration, with number 18 OP Old Age of places Priory (The) D51_D01_S58301_PRIORY_V21997_230505_Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users who may be accommodated in the home at any one time is 18 Date of last inspection 18th 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 accomodation to service users who are over the age of 65 years. The home can also offer care to service users who 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. 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 and one waking night staff member on duty. Priory (The) D51_D01_S58301_PRIORY_V21997_230505_Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place over 6 hours on 23rd May 2004. The new manager and the owner were present during parts of the inspection. The inspector spoke to seven service users and four staff. Three hours of the inspection was spent with service users and staff. The midday meal was sampled, and the following records were seen: care plans, risk assessments, medication records, accident records, staff recruitment and training records and the fire safety records. There was a partial tour of the premises and the inspector sampled the two course lunch. The inspector sent a pre inspection questionnaire to the home and received responses from service users and their relatives. The comments made were very positive about the care in the home. There has been a change of manager. The new manager is still in the probationary period of employment. There are planned changes to the premises under consultation. What the service does well: The owners and staff of the home are to be commended in the way they have managed the changes in the past year. This does not seem to have had an adverse effect on the service users. Service users spoke highly of the care they receive in the home. Comments included ‘I have the freedom to please myself’, ‘ the atmosphere in the home felt right when I moved here’, as well as more general comments about how kind the staff were and that the food was very good. Comments received from the surveys included ‘carers are wonderful’, ‘positive experience, very satisfied so far’, ‘The Priory take a lot of care to provide a homely environment, genuine interest in the welfare of … this is reassuring to all of us’. In house staff training continues monthly with evidence to support this. Service users were clear about how to use the complaint procedure in the home and staff were clear about how to support and action any concerns that service users may have. There was a relaxed atmosphere in the home, with conversation and activities between staff and service users. There has been a very low turnover of staff. Priory (The) D51_D01_S58301_PRIORY_V21997_230505_Stage4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Priory (The) D51_D01_S58301_PRIORY_V21997_230505_Stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Priory (The) D51_D01_S58301_PRIORY_V21997_230505_Stage4.doc Version 1.30 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 standard(s) 3 Standard 6 is not applicable to this home. Service users are assessed, so that their needs can be met when they move to the home. EVIDENCE: There have been three new service users in recent months. The inspector spoke to all three and case tracked two service users records. There is an assessment document and on occasion, the assessment takes place over a day visit in the home, completed by the manager. There are also additional records from previous placements and a family history that is compiled by the service users’ relatives. This helps to provide a clear picture of the service users needs, leading to care plans being written using a Cardex system. There is a different care plan in the service users’ own bedroom. Priory (The) D51_D01_S58301_PRIORY_V21997_230505_Stage4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 Care plans show how the care is to be provided to service users. Health care needs are fully met apart from two specific risks, which had not been fully addressed. This could lead to these service users being at risk in the home. Service users manage their own medication safely. There are a small number of medication recording errors that could put service users at risk. Service users are treated with dignity and respect by staff in the home. EVIDENCE: There is a cardex system in place that records all of the service users’ care plans. There are also individual service user plans in bedrooms that are in a different style. The cardex format contains details of the service users care needs. On case tracking the files, one file was different from all of the others, as it did not contain the same breadth of information. It did not match the care plan that was in the service user’s bedroom. There are two different risk assessment formats, but not all of the risks that may be relevant for service users had been assessed. Specifically; where radiators have not been covered; where there is a high risk of falls or other behaviour, and where service users preferred activities could pose a hazard. Priory (The) D51_D01_S58301_PRIORY_V21997_230505_Stage4.doc Version 1.30 Page 10 Medication records showed that on occasions, staff had not recorded the code when medication had not been administered and there were inconsistencies on the administration record sheets that were discussed at length with the owner and the manager. These errors are partly due to the repeat prescriptions and monitored dosage systems, which the manager plans to sort out. There are risk assessments in place when service users administer their own medication and this is held safely in the service users’ own room at this time. Staff were observed to treat the service users with respect and dignity and service users commented on how approachable and friendly the staff were. One service user commented that they ‘couldn’t imagine living anywhere else, or that there would be any maltreatment in the home.’ The service user went on to say that the reports of abuse in care homes were unimaginable at The Priory. There are requirements regarding risk assessments, medication training and medication record keeping. Staff have received medication training from their supplier. Priory (The) D51_D01_S58301_PRIORY_V21997_230505_Stage4.doc Version 1.30 Page 11 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 standard(s) 12, 15 Service users enjoy choosing from a range of activities in the home and have the freedom to select what they enjoy taking part in. Service users enjoy well prepared and nutritious meals. EVIDENCE: Service users were very clear that they enjoyed living at the home. There is a wide range of activities, both inside and outside of the home. One service user had especially enjoyed a recent religious service held in the home. There are clear records of the types of activities that take place and who took part. The newsletter also shows the range of trips and that families and friends are involved. Some service users told the inspector they prefer to stay in their room from time to time, but still felt involved in the home and shared mealtimes with other service users. One service user summed it up by saying ‘I have the freedom to do what I choose here’. Service users told the inspector about a recent change to the breakfast menu as a cooked breakfast is available on occasion, which was much appreciated. The sampled lunch meal was tasty and well received by the service users. Service users all spoke highly of the food and said that they would be given a choice or an alternative if there were something they did not like. Priory (The) D51_D01_S58301_PRIORY_V21997_230505_Stage4.doc Version 1.30 Page 12 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 standard(s) 16,18 Service users were clear that they feel able to make a complaint using the system in the home. Staff were clear about how they would support service users with minor complaints. There is an atmosphere that supports service users in expressing their needs and any dissatisfaction they may have. Service users did not have clear information independent of the manager or the owner so that they could contact the Commission. Adults are protected from abuse as staff are aware of the local procedure and training records show they have received training. EVIDENCE: The pre inspection questionnaire showed that there had been no complaints made to the home, or the CSCI and there have been no vulnerable adult procedure investigations. A discussion with service users and staff showed that both groups were clear about how they would address minor complaints. One service user said that if there was a complaint that they would contact the CSCI, although there was no information readily available to them to enable this to happen. Service users may have to approach staff, the manager or owner for this information. There is a commitment statement on display in various parts of the home. This statement has the contact details for the CSCI. The owner plans to ensure that information is readily available to service users, as this would provide them with the contact details directly. Service users families have copies of the contracts which details the contact details for the CSCI. Priory (The) D51_D01_S58301_PRIORY_V21997_230505_Stage4.doc Version 1.30 Page 13 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 standard(s) 19, 23, 26 The Priory is homely, attractive, well maintained and suitable to meet the needs of the service users who live there. Service users could be at risk from unguarded or hot radiators. EVIDENCE: This is a well maintained and attractively decorated home. Service users appeared to find their way about the home with ease and staff were observed providing support when it was needed. There are no radiator covers in place. Some risk assessments are in place, but not for all service users. The inspector discussed this with the owner and the manager, as an action plan needs to be devised, showing when the radiators that pose the highest risk to service users are to be covered, over the forthcoming year. In the meantime, risk assessments must be written for those service users affected. Service users told the inspector they were very pleased with their rooms, which are all above the national minimum standards in size and most have ensuite facilities. Service users were able to bring items from home, which added to the homely feeling of the bedrooms. Priory (The) D51_D01_S58301_PRIORY_V21997_230505_Stage4.doc Version 1.30 Page 14 There is a laundry on the ground floor and staff were observed carrying out some laundry tasks during the day. The home was very clean and tidy on the day of inspection. Priory (The) D51_D01_S58301_PRIORY_V21997_230505_Stage4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 There are sufficient staff on duty at all times to meet the needs of the service users. Service users are protected by a robust recruitment procedure. Staff receive regular training to ensure that they can meet the needs of the service users. EVIDENCE: There are three staff on duty during the morning and two staff on duty in the afternoon, with one waking night staff. On occasion, there is an extra person on duty in the morning. This means that staff have the time to sit and talk to the service users and engage them in activities at various times of the day. The manager is on duty in addition to these hours. Service users clearly valued the time that staff had to spend with them. The recruitment records for the newest staff were checked and these were all in order. Staff receive a training session at least once a month and the most recent sessions have been hoist training, abuse awareness, palliative care, first aid and fire safety awareness. The majority of the staff team have received dementia training in the last year. There are monthly staff meetings and regular supervision sessions. Staff commented on the level of training in the home and how this enables them to provide the right care for service users. Priory (The) D51_D01_S58301_PRIORY_V21997_230505_Stage4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Service users’ fire safety is well managed. EVIDENCE: The fire safety records were all in order. No other parts of these standards were assessed on this occasion as detailed information on safety systems and checks had been provided as part of the pre inspection questionnaire. Priory (The) D51_D01_S58301_PRIORY_V21997_230505_Stage4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 4 COMPLAINTS AND PROTECTION 4 x x x 3 x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x 3 Priory (The) D51_D01_S58301_PRIORY_V21997_230505_Stage4.doc Version 1.30 Page 18 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP8 Regulation 13(4) (a) Requirement Radiators must be individually risk assessed with an action plan that shows when they will be covered. 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. Staff must receive medication training from an accredited source. Staff must have their competence assesed after they have received training. Timescale for action 1st August 2005 1st July 2005 2. OP9 13(2) 3. OP9 13(2) 1st October 2005 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. Refer to Standard OP7 OP16 Good Practice Recommendations Service users should be more involved in understanding the content of the care plans in their rooms. Service users should have the contact details for the CSCI independently. Priory (The) D51_D01_S58301_PRIORY_V21997_230505_Stage4.doc Version 1.30 Page 19 Commission for Social Care Inspection Avonbridge House Chippenham Wiltshire 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) D51_D01_S58301_PRIORY_V21997_230505_Stage4.doc Version 1.30 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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