Inspection on 14/11/05 for The Priory

This inspection was carried out on 14th 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

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 11/12/06

The Priory 06/10/06

The Priory 08/05/06

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 Mr Ian Harris Unannounced Inspection 14th November 2005 08:00 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.V266087.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. The Priory DS0000064067.V266087.R01.S.doc Version 5.0 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 Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places The Priory DS0000064067.V266087.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Priory Nursing and Residential Home may provide care for a maximum of 37 older people, of whom uo to 17 may require low to medium dependency nursing care. Staff involved iin 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. 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 2. 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, ie - 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. 12th May 2005 Date of last inspection Brief Description of the Service: The Priory is a privately owned care home providing Nursing and residential care. It is situated on the eastern edge of the Shropshire town of Wellington, With local amenities available a short walk away. The Building comprises of a large converted town house with a purpose built ‘Nursing’ extension add in recent years. The home is set in its own grounds and has a car park at the front of the building. The home is registered to provide care for a maximum of 37 residents 17 of which may require nursing care. The Priory DS0000064067.V266087.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 5 hours. The main purpose of the inspection was to check the progress made by the home regarding the recommendations and requirements made in the last inspection report. The fullest co-operation was given to the inspection officer by the Acting Care Manager staff and residents. During the inspection a tour of the premises took place and staff and care records were inspected. Also staff rotas and general records regarding the maintenance of the home were checked. 6 of the 40 Care staff were on duty, and 8 of the 37 residents were spoken to. . All the residents who could express themselves in a meaningful way stated that they were happy and contented and, “well looked after”, “The staff are golden. However a number of residents said they worked hard and were always rushed. On the day of inspection the Home is in the process of being redecorated and refurbished and this, is causing some disruption to the residents. The change of ownership has led to delay in the appointment and Registration with CSCI of a Manager/Matron. However the Acting Matron (Mrs. Mel Thomson) and the staff team has worked hard, and effectively, to minimise decline of care standards during this time. Many of the ‘Requirements’, cited at the announced Inspection held on 12th May 2005, required financial investment, and action to meet these has also been delayed by the sale process. However, some areas have shown improvement, e.g. care planning, medicine management, the commencement of a programme of refurbishment and decoration of the public areas. Residents and spoken with were keen to inform the Inspector that they considered Staff were to be applauded for maintaining their enthusiasm, and level of input, in caring for the Residents during this difficult time. What the service does well: The Staff are doggedly maintaining a generally good level of care despite the pressures relating to the major redecoration and refurbishment programme that is taking place at present. The Priory DS0000064067.V266087.R01.S.doc Version 5.0 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 Priory DS0000064067.V266087.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 The Priory DS0000064067.V266087.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): 1 The home provides good clear accurate information regarding the service provided, which is available in the reception area of the home EVIDENCE: The statement of purpose and the service user’s guide are available in the hall. Also a copy of the last inspection report is available to anyone interested. It was noted the staff at the home are proactive in inviting prospective residents and their families to visit the home and ask any questions they may have regarding the services provided in order to make an informed choice. It was confirmed by a resident recently admitted to the home that they had been invited to the home for lunch before moving in. The Priory DS0000064067.V266087.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9,and 11 Care provided by the Home is effective in meeting assessed care needs as set out in each individual Resident’s Care Plan. The storage, administration and disposal of medicines are in accordance with accepted good practice. EVIDENCE: Medication is administered by means of a Boot’s monitored dosage system. From observation made during the inspection and the inspection of the records the system appears to be working very well. The home receives good support from the Boot’s pharmacist who does a three monthly audit of the homes medication. All Care Staff have been trained to use the system before they are allowed to administer medication. Documentation for identifying individual Resident’s care needs, assessing risk and reporting progress were reviewed and found to be comprehensive and well maintained, thus indicating care needs are generally well met. Care Plans were seen to be well organised, clearly written and up-to-date. Operational Policies and Procedures relating to medicine management were reviewed and found to be comprehensive and up-to-date. The home has clear policies with regard to dying and death. The Priory DS0000064067.V266087.R01.S.doc Version 5.0 Page 10 The Care Manager and Care Staff are conscious of the need to provide extra support to the residents in their final days at the home. All the Staff are very aware of the need to be particularly sensitive, caring and attentive to the residents needs prior to their death. The care manager is also aware of the support the staff should provide to relatives and colleagues. Resident’s relatives are encouraged to be fully involved in the residents care at this particular time. The Priory DS0000064067.V266087.R01.S.doc Version 5.0 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 the following standard(s): 12,14 and 15 The home provides a stimulating experience for the residents where they are encouraged to maintain their independence as much as possible The home provides a range of social activities within the home designed to the capabilities of the residents The meals in the home are good, offering both choice and variety and also catering for special dietary needs. EVIDENCE: The home has a Staff member designated to organised social and leisure activities and identify interests that the residents wish to pursue. This has proved very successful in promoting and encouraging participation in the programme of activities. Musical evenings, bingo and arts and crafts are some of the activities that have recently been on offer. However’ it was noted the lack of shopping trips or outings outside of the home. The observations made, examination of menus and the comments received from the residents confirmed that there has been an improvement in the meals, and particular attention is given to the residents’ individual preferences. The Priory DS0000064067.V266087.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18 The home has a good complaints procedure with some evidence that residents’ views are listened to and acted upon. The home has good policies and procedures regarding protection from abuse, which includes a whistle blowing policy. EVIDENCE: The home has a comprehensive complaints procedure. The residents and relatives are made aware of the procedure through the statement of their terms and conditions of residence, the service users guide that is placed in every bedroom and a notice on the notice board in the hall. The home has a complaints book in which all complaints are recorded. It was noted that the home and the commission have not received any formal complaints since the last inspection. The home has received one unanimous complaint this and all minor complaints have been dealt with appropriately and quickly. Residents stated that if they had a problem they would speak with the care manager who would resolve it. The home has policies and procedures regarding Prevention of Abuse, which includes a Whistle-Blowing policy. These issues are also covered in the N.V.Q. training, which all the Care Staff is undergoing. There have been no incidents that have needed to be recorded or reported. The Priory DS0000064067.V266087.R01.S.doc Version 5.0 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 the following standard(s): 19 and 26 The environment is sufficiently spacious, but several areas of the Home are in need of refurbishment/redecoration. Access to the Home is unmonitored and presents an unacceptable security risk. Residents have access to lavatory and washing facilities and specialist equipment consistent with their needs. EVIDENCE: Whilst the location and general layout of the Home is suitable for the provision of both residential and nursing care, many areas, particularly those in the older (original) part of the Home, are tired and worn and in need of redecoration and refurbishment and at the time of this inspection work has already started on redecorating the public areas and corridors. When this is completed a rolling programme of redecorating the residents bedrooms start in the older part of the building should be undertaken. When the redecoration is completed all the carpets throughout the public areas of the home must be replaced. The Home has several dining and lounge/sitting areas, all offering adequate space, and providing variety in outlook and size. The Priory DS0000064067.V266087.R01.S.doc Version 5.0 Page 14 Corridors are of good width and, although, there are some areas with a pronounced incline, i.e. where the original building connects with the more recent parts of the Home, these do not appear to present difficulties to Service Users or Care Staff. However it was noted that the home does not have a walk in shower thus limiting residents’ choice of bathing. Consideration should be given to providing a walk in shower room. Also it was noted that the equipment in the kitchen would be improved by the provision of an industrial food processor and meat slicer. The Home has a laundry room comprising one washing machine and one drying machine, with no back up facility should a machine fail. The room is situated within the ‘Nursing’ Section of the Home, thus requiring movement of soiled linen from the ‘Residential’ to the ‘Nursing’ part of the Home, and presenting a serious opportunity for the spread of infection. In addition, at peak periods 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 ‘back-up’ of soiled linen - presenting a further infection control problem. The lift in the home has recently been inspected because of problems and the lift engineer has made a number of recommendations regarding the maintenance, which must be addressed. Public access to the Home is via the ‘front’ door of the Home, which is unlocked during daylight hours and, unless a member of Staff is present in the adjacent Office, there is no observation, or control, of movement of visitors. At times it is possible to walk to each extreme part of the Home without encountering or being challenged by a member of Staff. The Acting Matron/Manager is both aware, and equally concerned, about this situation. Consideration should be given to the fitting of a digital key lock that is wired to the fire alarm to the door leading from the reception area to the home. The Priory DS0000064067.V266087.R01.S.doc Version 5.0 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 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, and 30 Staff numbers and skill-mix on duty were sufficient to meet the assessed care needs of the current Residents. There is a stable and enthusiastic staff group committed to providing the Residents with a quality of life, which meets their individual requirements and aspirations. EVIDENCE: The current Staff duty rota, and those from immediately preceding weeks, were examined, and demonstrated staff numbers and skill-mix to be in accordance with the Statutory Staffing Notice. Discussions held with Residents produced comments relating to Staff which were very positive, including –“…they look after us very well”, “… “…nothing is too much trouble,” “…they look after us very well…”. It was noted that the requirements of CRB checks are not being met prior to Staff commencing work at the home there is not full compliance with this Standard. Staff training records showed evidence of appropriate training taking place. However the home has not yet achieved the minimum number of N.V.Q. trained care staff. The Priory DS0000064067.V266087.R01.S.doc Version 5.0 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 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): 32,and 38 The Home is managed well on a ‘day to day’ basis by Acting Care Manager. All Staff contributing to ensuring that Residents’ best interests are served. However, the Standard is not met, as the Home still does not have a Matron/Manager formally Registered with the CSCI, as required by Regulation 9. ‘Health and Safety’ matters are conducted satisfactorily. EVIDENCE: It was noted that the Acting Care Manager is on the rota as the nurse in charge five days a week this is unacceptable, in a home of this size. It is expected that the home provides a minimum of 37 hours per week management hours. The provision of a computer for the officer would be a great improvement and help improve and reduce some of the administrative tasks. The Priory DS0000064067.V266087.R01.S.doc Version 5.0 Page 17 There was evidence in Staff Records of training in fire prevention, chemical substance awareness, food hygiene, and moving and handling. Documentation reviewed demonstrated awareness by the Home’s Management of responsibilities under the Health and Safety Legislation. Matters pertaining to COSHH appeared satisfactory, and the necessary service certificates were available to view. All relevant training materials relating to safe working practices are available to Staff. There was an inspection by the Fire Prevention Officer on 2nd November 2005 and a number of minor issue were highlighted that are mainly due to the redecoration that is taking place within the home that must be addressed. The Priory DS0000064067.V266087.R01.S.doc Version 5.0 Page 18 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 3 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X X STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 2 X X X X X 2 The Priory DS0000064067.V266087.R01.S.doc Version 5.0 Page 19 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 OP31 Regulation 26 Requirement The registered person must ensure that copies of the monthly regulation 26 visit to the home are sent to the commission. The registered person must ensure that the home achieves the minimum standard regarding the number of N.V.Q. trained Care staff. The registered person must ensure that all staff employment files must contain the all the items listed in Standard 29 and in Schedule 2 of the Regulations. That the Acting Care Manager must make application to the CSCI to be approved as Registered Matron/Manager. The registered person must ensure that the acting Care Managers is not on the rota as the nurse in charge. She should have a minimum of 37 hours per week to manage the home. The registered person must ensure that all the carpets in the public areas are replaced when the redecoration is completed. DS0000064067.V266087.R01.S.doc Timescale for action 01/12/05 2 OP29 18 (a) 01/01/06 3 OP29 7, 9,19, Schedule 2 9.-(1)(2) 01/12/05 4 OP31 01/12/05 5 OP31 9.-(1)(2) 12/12/05 6 OP19 23 (2) (b) 01/12/06 The Priory Version 5.0 Page 20 7 OP19 23 (2) (n) 8 OP38 23 (4) (a) 9 OP26 16.(2)(e)(f) 10 OP26 16.(2)(e)(f) 11 OP19 12.-(1)(a) 12 OP19 23.(2)(b)(d) 13 OP19 23.(2)(b)(d) The registered person must ensure that all the recommendation of the lift engineers report are addressed. The registered person must ensure that all the recommendations of the Fire Prevention Officer report dated 02/11/05 are addressed The registered person must commence and complete the work to increase the laundering capacity, within an agreed timescale. Previous target date (12/05/05) unmet. The registered 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 (12/05/05.) unmet. The registered person must ensure that control of access to the Home is reviewed and action taken to ensure the security of Service Users, Staff and their possessions. The CSCI is to be advised, in writing, of proposals and action taken. Previous target date (12/05/05.) unmet. The registered person must provide the CSCI with a maintenance programme to ensure sound fabric and good quality décor at the Home. Previous target date (12/05/05.) unmet. The registered person must provide the CSCI with a plan for redecoration/refurbishment, together with a programme, which includes dates for commencement and completion of work. Previous target date (12/05/05.) unmet. 01/12/05 01/12/05 01/02/06 01/12/05 01/12/05 01/12/05 01/12/05 The Priory DS0000064067.V266087.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 OP31 OP19 OP19 Good Practice Recommendations That a computer is provided for the office. That a industrial food processor and meat slicer be provided in the kitchen. That consideration is made of the provision of a walk in shower. The Priory DS0000064067.V266087.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE 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 The Priory DS0000064067.V266087.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!