Inspection on 11/12/06 for The Priory

This inspection was carried out on 11th December 2006.

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

The Priory 10/02/10

The Priory 02/02/10

The Priory 20/10/09

The Priory 30/06/09

The Priory 02/12/08

The Priory 21/10/08

The Priory 08/07/08

The Priory 31/07/07

The Priory 02/03/07

The Priory 06/10/06

The Priory 08/05/06

The Priory 14/11/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Priory Springhill Wellington Telford Shropshire TF1 3NA Lead Inspector Keith Salmon Key Unannounced Inspection 11th December 2006 2:00 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 The Priory DS0000064067.V323502.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. The Priory DS0000064067.V323502.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Priory Address Springhill Wellington Telford Shropshire TF1 3NA 01952 242535 01952 641577 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) Wellcare Management Ltd *** Post Vacant *** Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places The Priory DS0000064067.V323502.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Priory Nursing and Residential Home may provide care for a maximum of 37 older people, of whom up to 25 may require low to medium dependency nursing care. Staff involved in the care of Residents must be suitably qualified, competent and experienced persons who are deployed in such number/skill-mix so as o be minimally in accordance with the Staffing Notice issued by Shropshire Health Authority. 08:00-14:00 22:00-08:00 1 Qualified Nurse Qualified Nurse (RGN or EN) or EN) 6 Care Staff Care Staff 14:00-22:00 1 Qualified Nurse (RGN or EN) 4 Care Staff 1 (RGN 3 3. NB - additional staff must be on duty when high dependency service users are accommodated - these minimum levels are for direct nursing and personal care only, i.e. - they do not include ancillary staff. The above numbers may include the Manager when he/she is engaged in direct care provision, but are exclusive of the Manager when he/she is carrying out managerial duties. Date of last inspection Brief Description of the Service: Situated on the eastern edge of the Shropshire town of Wellington, with local amenities available a short walk away, The Priory is a privately owned Care Home providing Nursing and residential care. Set in its own grounds, with a car park to the front, the building comprises a large converted town house with a purpose built ‘Nursing’ extension added in recent years, and is registered to provide care for a maximum of 37 residents 17 of which may require nursing care. The Priory DS0000064067.V323502.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This ‘Key’ Unannounced Inspection commenced at 2.00pm, concluded at 5.30pm (a total 3.5 hours) was conducted by Mr Keith Salmon and undertaken as a follow-up to the ‘Key’ Unannounced Inspection, carried out on 6 October 2006, and a management review meeting held on 17 November 2006, at the Shrewsbury Office, between Mr. Pritpal Singh, the Owner/Responsible Person, Mr Brian Lock, Regulation Manager (CSCI) and Keith Salmon. Present for the Home was Mrs. Barbara Johnston, who is functioning as the Acting Manager. At the ‘Key’ Inspection held in October the Inspector was concerned to find little advancement in relation to ‘Requirements’ cited at the previous ‘Random’ Inspection, held on 22 September. Areas of particular concern were staffing levels and lack of progress in providing improved laundry facilities. Therefore, it was decided to invite Mr. Singh to attend the Shrewsbury Office to personally explain what action was being taken to address the identified shortfalls. The outcome of this meeting was Mr. Singh undertook to provide the CSCI with an Action Plan by the end of December 2006. Whilst conducting this Inspection the Inspector was contacted by Mr Singh, who stated the Action Plan was close to completion and would be forwarded to the CSCI over the coming days. This Report is based on observations made during a tour of the Home, a review of care related documentation, staff duty rotas, staff files, plus a range of other documents/records reflecting the general operation of the Home. Over the course of the two visits the Inspector held 1:1 discussions with the Acting Manager, the Home’s Administrator, 5 Residents, 5 Visitors, plus several members of Staff. What the service does well: Hitherto it was difficult to identify any particular area of care the service does well. The evidence and judgements made in this Report, and reports from CSCI Inspections recently preceding this one, give a very clear indication that The Priory is struggling to achieve the quality of care service as set out in the Care Home Regulations and National Minimum Standards. However, it should be recorded that despite the apparent on-going difficulties presented by the uncertainties of change in ownership, and Manager, the Staff have strived to maintain a good level of morale and continued to (as one visitor said) “…put the Residents first”. The Priory DS0000064067.V323502.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. The Priory DS0000064067.V323502.R01.S.doc Version 5.2 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 The Priory DS0000064067.V323502.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is possible that, on occasions, insufficient care is exercised in ensuring the Home is able to effectively meet Residents’ care needs. EVIDENCE: It was a ‘Requirement’ of the previous Inspection that, for all prospective Residents, a pre-admission assessment must be undertaken by a suitably trained/experienced member of Staff, and written evidence retained within the Residents care planning documentation. A review of documentation relating to the three most recently admitted Residents showed pre-admission care needs assessment had been completed and was undertaken by suitably trained/experienced members of Staff. This ‘Requirement has been met. The Priory DS0000064067.V323502.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The new model of Care Plan, introduced during the Autumn, is of a comprehensive design and easy to read. However, utilisation is incomplete in that a substantial proportion of Residents’ Care Plans have yet to be transferred to the new model. The care provided by the Home is effective in meeting the Residents’ assessed care needs, and is delivered considerately and effectively. The storage, administration, and disposal of medicines are in accordance with accepted good practice. EVIDENCE: ‘Case Tracking’ involved a review of Care Plans/Files relating to nine Residents’, i.e. the three most recently admitted Residents, plus 6 selected at random, revealed that whilst generally Care Plans were found to be comprehensively completed with current entries, documentation for a substantial proportion of Residents still involves use of the previous Care Plan. The Priory DS0000064067.V323502.R01.S.doc Version 5.2 Page 10 The Acting Manager acknowledges this and advised that the process of transferring Care Plans of all the Residents to the new documentation has not yet been completed. The Inspector accepts that with the previous Manager having recently left pressures on the remaining Senior Staff have resulted in a slowing of the process of transferring from the ‘old’ to ‘new’ model. Therefore, this ‘Requirement’ will remain and must be completed as a matter of urgency. The Home has Policies and Procedures for the management and administration of medicines, which are an integral part of the Home’s Staff Induction Programme. Medicines are administered by means of a Boots monitored dosage system with regular support from a Boots’ Pharmacist. The storage, administration, and disposal of medicines are in accordance with accepted good practice. The Inspector observed Staff relating to Residents, and their families/visitors, in a friendly and respectful manner. The Priory DS0000064067.V323502.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A limited range of leisure opportunities is provided, which are consistent with Residents’ capabilities. However, as a group, Staff work hard at helping Residents experience an interesting and varied lifestyle. Residents are enabled to conduct the pattern of their day, where possible, as they wish, including contact with family and friends, and continuation of religious practices. There is a daily choice of meals from a menu offering traditional fare. The variety and quality offered has shown some improvement. EVIDENCE: The Home has improved the range of activities offered on site, which are led by a Carer who has additional responsibilities as ‘Activities Coordinator’. The main provision is by way of relatively brief, but frequent, activities focussed on meeting Resident’s capabilities, e.g. span of attention. However, as mentioned in the previous Inspection Reports, there is a need to offer Residents more opportunities for trips and outings. Also, Residents informed the Inspector they greatly enjoyed the occasional visiting entertainers, a provision they would like to see more of. Residents expressed the view that they were generally satisfied with the quality of food provided. The Priory DS0000064067.V323502.R01.S.doc Version 5.2 Page 12 Although Staff have experienced two difficult periods of change during the past two years their commitment to improving the quality of life for Residents is reflected in the organising of the recent ‘Xmas Fare’. This was arranged by Staff and held at the end November in the main lounge. The event comprised stalls selling seasonal artefacts/produce, and several raffles, which raised £600 for the Residents’ ‘comfort fund’. One Resident informed the Inspector how much she enjoyed the event and that she had won the raffle for the second time this year. Several Residents commented that they liked the food provided, with one adding there had been an improvement some months ago and this had been maintained. The Priory DS0000064067.V323502.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home’s Management and Staff are receptive to issues and complaints raised by Residents and relatives/visitors. Generally, they are able to provide and implement an effective response. The interests of Residents are protected through ready access to information relating to advocacy services and the Home’s Complaints Procedure. Staff are aware of their role in protecting Residents from abuse. EVIDENCE: Complaints Procedure details are included in the Service User Guide and are displayed prominently for the benefit of visitors. There are policies and procedures in place intended to provide protection for vulnerable people. These fully meet the requirements of this Standard and Staff Training Files confirm the topic is covered at induction and through on-going staff training. The Priory DS0000064067.V323502.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, & 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Some areas of the Home have shown marked improvement in décor/ refurbishment. However, there remains the need for a continuation of such improvement before the judgement on this ‘outcome’ area can be raised. There remains the absence of a statement with regard to long-term plans for on-going refurbishment, redecoration, replacement of furniture and equipment, and laundry provision. EVIDENCE: The redecoration programme has re-commenced and has now begun to make a positive impact on the general ambience of the Home. Specifically: In the original part of the building the staircase, corridors and some bedrooms have been redecorated in lighter colours. The Priory DS0000064067.V323502.R01.S.doc Version 5.2 Page 15 Ceiling tiles, which were variously damaged, stained or missing have been replaced. The room previously used as the lounge has been converted into an attractive dining room. The lounge, in turn, has been recreated in the adjacent room. This room offers better views to the front of the house and has the added facility of closer proximity to a toilet. The Inspector also observed new radiator covers, which are to replace the current ‘cage-like’ models located in the ‘nursing’ section of the Home. All of the above activity provides a welcome indication that the strategic management of the Home is receiving the attention necessary to ensure the outstanding Requirements relating this ‘Outcome’ area may be moving towards satisfactory resolution. A ‘Requirement’ cited at previous Inspections was:• “The Responsible Person must send to the CSCI for approval plans for increasing the capacity for the laundering of bed linen and Service Users’ personal clothing.” Inspection of the laundry demonstrated there has been no action whatsoever in respect of the development of laundry services. To reiterate comments made in earlier Reports, and the immediately preceding ‘Key’ Inspection Report, the siting and capacity of the laundry are of serious concern, i.e. the laundry room is situated within the ‘Nursing’ Section of the Home, thus requiring movement of soiled linen from the ‘Residential’ to the ‘Nursing’ section. In addition, the laundry facility comprises one washing machine and one drying machine with no back-up facility should a machine fail. Both of these aspects present serious opportunity for the spread of infection. Furthermore, at peak periods of activity the laundry room does not offer adequate floor space for the reception, sorting and onward management of linen and clothing, with a resultant overloading of the system and a ‘back-log’ of soiled linen. All of these factors contrive to present a major infection control risk. During this visit the Inspector was informed of plans to re-provide the laundry facility in an existing ground floor bathroom located in the original part of the Home. The proposal includes ‘knocking through’ the wall into the adjacent storeroom thus providing a larger area. The Administrator was reminded that no building works in respect of this should be commenced before architect’s plans are approved by CSCI. The Priory DS0000064067.V323502.R01.S.doc Version 5.2 Page 16 This scheme involves a proposal to relocate the ‘Parker’ bath from said bathroom to a second ground floor bathroom, which has a standard bath, and, the Inspector was informed, is rarely used. This apparent reduction in bathing provision will need CSCI agreement before the laundry proposals can commence. The Inspector also found two of the Home’s bathrooms to be out of use due to faulty baths, which are awaiting repair/replacement. In addition both bathrooms were being utilised as repositories for unused equipment. This is not acceptable as this renders the toilets, within each bathroom, inaccessible for Residents’ use. Steps must be taken to resolve the matter of the unavailability of the baths, and equipment stored in these areas must be removed and stored in a safe area, which does not encroach on areas required for use by Residents. The Inspector was informed that two ‘Parker’ Baths are on order and should be delivered in the near future. The Priory DS0000064067.V323502.R01.S.doc Version 5.2 Page 17 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): 27,28,29 & 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff numbers on duty and skill-mix are not sufficient to meet the assessed care needs of current Residents. Recruitment and employment practices are consistent with the safeguarding of Residents. The on-going provision of training for Care Staff, in accordance with individual Staff Member’s learning needs, has declined and is currently only satisfactory. EVIDENCE: Discussions held with Residents and Visitors produced mixed comments relating to Staff, including “…they look after us very well”, “…I like being here”, but more critically “…the Staff seem under much more pressure than they used to be,” “…they (the staff) don’t respond as quickly as they should.” These latter comments, together with comments from members of Care Staff who stated they felt exposed due to increased work pressures, raise questions concerning the levels of staffing within the Home – a matter already addressed by a ‘Requirement’ cited at the immediately preceding Inspection, i.e. “The Registered Person must ensure care staff be increased by two full staff in the daytime.” This was deemed necessary due to the increased dependency levels of several Residents. This ‘Requirement’ has not been met. Scrutiny of current Staff duty rotas, and those from the immediately preceding months, demonstrated The Priory DS0000064067.V323502.R01.S.doc Version 5.2 Page 18 Staff numbers, and skill-mix, frequently do not meet the minimum requirements of Item 2 of the ‘Conditions of Registration’ pertaining to the Home, which states: ‘Staff involved in the care of Residents must be suitably qualified, competent and experienced persons, who are deployed in such number/skill-mix so as to be minimally in accordance with the Staffing Notice issued by Shropshire Health Authority.’ Specifically this Notice requires that each day staffing numbers and skill-mix must be as follows: During the period 08:00 to 14:00 there will be on duty a minimum of 1 Qualified Nurse (RGN or EN) and 6 Care Staff. During the period 14.00 to 22.00 there will be on duty a minimum of 1 Qualified Nurse (RGN or EN) and 4 Care Staff. During the period 22:00 to 08:00 there will be on duty a minimum of 1 Qualified Nurse (RGN or EN) and 3 Care Staff. Following the October ‘Key’ Inspection a detailed review of the months of July, August and September 2006, demonstrated staff cover, as indicated on the ‘working’ copy of the staff duty rotas, failed to meet the minimum staffing requirements as follows: The minimum required level of staffing was achieved for only: 37 of shifts 0800 to 1400 22 of shifts between 14.00 and 17.00 47 of shifts between 17.00 and 22.00 55 of night shifts. An inspection of account dockets, reflecting the use of agency staff, suggested some reduction in the failure to meet Conditions of Service to some small degree. However, there is a serious concern that staffing levels persistently fail to meet the levels set out in the Staffing Notice, which is a Statutory Notice and must be adhered to, i.e. the levels, and mix of staffing, as set out in the Staffing Notice, must be provided, as the minimum, for 100 of shifts. A review of the duty roster for November 2006 demonstrated that, although there was minor improvement, the Home still failed to meet the requirements of the Staffing Notice. The Priory DS0000064067.V323502.R01.S.doc Version 5.2 Page 19 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): 31,33,35 & 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. General observation of day-to-day management indicates the current Acting Manager (Mrs. Barbara Johnson) is effectively maintaining good day-to-day provision of care to the Residents of the Priory. Despite some indication of improvement in Requirements being effectively addressed generally, long term management, remains poor. Residents are at risk due to a number of health and safety and infection control practices. EVIDENCE: Requirements relating to the ‘Management and Administration’, cited at previous Inspections, have not been met and remain outstanding, i.e. The Priory DS0000064067.V323502.R01.S.doc Version 5.2 Page 20 ‘Requirement’ relating to OP 31, Regulation 9-(1)(2): “The Acting Care Manager must make application to the CSCI to be approved as Registered Matron/Manager.” Target date 09/07/06 unmet. The Manager in post at the time of the previous Inspection has now terminated her contract and left the Home. The Inspector was informed that a new Manager has been recruited and will take up post on 3 January 2007. The new Manager must commence the process of applying to CSCI for approval to become ‘Registered Manager’ immediately following commencement of employment. ‘Requirement’ relating to OP 33, Regulation 24 (1) (a) and (b): The registered person must ensure that a Quality Assurance system is Implemented, within the Home, to ensure the views of Residents, Relatives and other Professionals, on the service, are obtained and an action plan drawn up to address any issues raised. Target date 06/07/06 unmet. The Inspector was informed the previously established practice of using Questionnaires to sample the views of ‘stakeholders’ had not been undertaken for some time. It is reiterated there also remain other matters of concern, relating to this ‘Outcome Group’, i.e. The laundry still has no facility for locking and being accessible to passing Residents, some of whom have dementia related illness, presents a serious health and safety hazard. In order to protect Residents, as an emergency and temporary measure only, the Inspector has agreed that a ‘high level’ bolt may be fixed to the laundry room door. It will remain a ‘Requirement’ that the Home is to fit a lock to the laundry door without further delay. There is still no written evidence of visits to the Home by the Responsible Person, or other designated employee of the Organisation, as required by Regulation 26. The Inspector was informed arrangements have now been instigated by the Responsible Person for Regulation 26 monitoring visits to be undertaken by an appointed agent. However, although one visit is reported to have taken place, at the time of this Inspection the CSCI had not received the required Report of the visit. Also, it was noted that Catering Staff are changing into their protective clothing in the staff toilet. This practice presents a cross-infection hazard and must cease. Suitable changing accommodation is to be provided elsewhere in the Home. The Priory DS0000064067.V323502.R01.S.doc Version 5.2 Page 21 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 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X 2 X X X X 1 STAFFING Standard No Score 27 1 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 1 The Priory DS0000064067.V323502.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15. – (1) Requirement The Manager must ensure that the change over to the new model of Care Plan is completed as soon as possible. The activities programme is to be reviewed and extended to include availability of outdoor trips etc and to take account of Service Users’ wishes. The Responsible Person must instigate an on-going refurbishment/redecoration/ replacement programme. This programme must include proposed completion dates for each element of work. Timescale for action 31/12/06 2. OP12 12. (1)(a) 31/12/06 3. OP19 23. – (2) (b)(c)(d) 31/12/06 4. OP19 23. – (2) (b)(c)(d) The Responsible Person must 31/12/06 forward to the CSCI a draft of the refurbishment/redecoration/ replacement programme, for agreement on the range of works to be undertaken, and on the proposed completion dates of such works. The Priory DS0000064067.V323502.R01.S.doc Version 5.2 Page 23 5. OP21 23. – (2)(j) 6. OP26 13. – (3), (4)(a)(b) (c) 16. – (2)(e) The Responsible Person must ensure the two damaged baths are repaired or replaced and the bathrooms brought back into use. The Responsible Person must ensure no building works, in respect of the relocation of the laundry, be commenced before architect’s plans are approved by CSCI. The Responsible Person must send to the CSCI, for approval by the Inspector, plans for increasing the capacity for the laundering of bed linen and Service Users personal clothing. Previous target date referring to staffing (12/06/05) unmet. The Responsible Person must ensure staffing levels, and skillmix are in accordance with the ‘Conditions of Service’. Previous target date (06/07/06) unmet. The Responsible Person must ensure that all staff receive training opportunities which enable them to meet the changing needs of the Residents Immediately following commencement in the post of Home Manager, i.e. 3 January 2007, the Manager must commence the process of application to the CSCI to be approved as Registered Matron/Manager. The Responsible Person (or an appropriate deputy) must visit the Home and submit to CSCI related reports of the visits in accordance with Regulation 26. DS0000064067.V323502.R01.S.doc 31/01/07 31/12/06 7. OP26 16.(2)(e)(f) 31/12/06 8. OP27 18.(1)(2)(3) 31/12/06 9. OP30 18.- (1) (c)(i)(ii) 28/02/07 10. OP31 9.-(1)(2) 31/01/07 11. OP33 26. (2)(3)(4) (5) 31/12/06 The Priory Version 5.2 Page 24 12. OP33 24 (1) (a) and (b) 13. OP38 12. -(1) (a) The Responsible Person must ensure that a Quality Assurance system is implemented within the Home to ensure the views on the service are obtained from Residents, Relatives and other Professionals, and an action plan drawn-up to address any issues raised. Previous target date (12/06/05.) unmet. The Responsible Person must ensure that a lock is provided to the laundry door, to prevent access by Residents when the laundry room is unattended. The Responsible Person must provide suitable changing room accommodation for catering staff. 31/12/06 31/12/06 14. OP38 23. – (3)(a) (i)(ii) 18/12/06 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 OP34 Good Practice Recommendations That the policy on the delegation of budgets is reviewed to allow the Manager greater autonomy. The Priory DS0000064067.V323502.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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. Extracts may not be used or reproduced without the express permission of CSCI The Priory DS0000064067.V323502.R01.S.doc Version 5.2 Page 26 - 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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