Inspection on 18/01/07 for The Priory

This inspection was carried out on 18th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 11/07/07

The Priory 20/07/06

The Priory 06/03/06

The Priory 05/07/05

The Priory 29/09/04

The Priory 27/04/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE The Priory Romford Road Pembury Tunbridge Wells Kent TN2 4AY Lead Inspector Lynnette Gajjar Key Unannounced Inspection 18th January 2007 09:20 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 DS0000039813.V325057.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 DS0000039813.V325057.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Priory Address Romford Road Pembury Tunbridge Wells Kent TN2 4AY 01892 823018 01892 825298 gill@thepriorypembury.co.uk 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) The Priory (Pembury) Ltd Gillian Daniels Care Home 32 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (18) of places The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th October 2006 Brief Description of the Service: The Priory is situated in a rural setting within Pembury near Tunbridge Wells. The Priory offers care for older people over 65 years of age; they have 18 places for elderly frail and 14 places for older people suffering from dementia. At the time of this inspection the majority of the service users in residence have a diagnosis of dementia. The current owners purchased the home in September 2003. The home is set in 4 ½ acres of woodland and garden that is mostly laid to grass. The home is an old house that is on four floors; there is lift access to all levels. The day areas are on the ground level; there are comfortable lounge areas and a dining room. The bedrooms are situated on each level; the basement also contains the kitchen, visitor’s room, laundry, the maintenance person’s room and storage. The weekly fees range from £401.00 to £550.00. These figures are based on rooms irrespective of funding arrangements. Extra charges are made for newspapers at cost; hairdressing from £5.20 upward and chiropody £15.60 weekly as required. The home’s last inspection report is available on request at the home. The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced key inspection in the year running from April 1st 2006. The inspection was undertaken by Regulation Manager Linda Ribbands and Regulatory Inspector Lynnette Gajjar, who were at the home from 9.15am to 5.15pm. Included also in this report is evidence gathered during a random inspection carried out on 13th October 2006 by Regulation Manager Linda Ribbands and Regulatory Inspector Maria Tucker, when immediate requirements were issued for urgent action by the organisation to promote the safety of service users. The current registered manager is on long term sick leave. Interim arrangements of an acting manager, Hazel Stace, who has been transferred from another home owned by the company, have been implemented since December 2006. There are plans in place for her to apply for registration for the home. This visit was spent talking directly with some service users privately and collectively, care and ancillary staff, the acting manager, provider and an external consultant employed by the home. Due to the nature of the service and cognitive difficulties experienced by some service users, it is difficult to reliably incorporate accurate reflections of the service users in the report. Judgements about quality of life and choices were taken from direct conversation with service users, staff and observation followed by discussion with care staff, and evidencing records held at the home. A tour of part of the premises was undertaken. Information was also gathered through a pre inspection questionnaire completed by the acting manager The home currently has 27 people in residence with 1 service user in hospital. Following reassessment of all the service users in December 2006, it was identified that 25 service users require dementia care. This figure takes the home over its current registration category by 11 placements. Therefore no new admissions for dementia care can be accepted at this time. The Provider plans to submit an application to CSCI to transfer the registration of the home to full dementia care, however work is required on the home and systems to ensure that they are fit for this purpose before this will be considered. From this second key inspection it is evident that the provider has made progress through their improvement plan since the random inspection on 13th October 2006 and the immediate requirements issued. There has been some improvements made towards meeting the key standards assessed. However due to the scale of work required to improve the safety and well being of The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 6 service users with cognitive disabilities, many outcome areas remain only partially met. As part of his response 28 days after receiving the draft KU report, the provider submitted further information detailing the action taken by the acting manager and himself to address some areas identified in this report. The Commission wishes to acknowledge the work undertaken since the inspection site visit but reiterates there is still work required to evidence that the systems and practices that are now in place, are sustainable. Evidence is also required that the systems provide an audit trail that is robust and protects service users’ safety and lifestyle. What the service does well: What has improved since the last inspection? A new electronic care planning system has been introduced to the home. Data is being entered onto this system that offers better information and guidelines for staff to support service users. The system details weight loss/gain, number of falls in a month etc and this will better promote the health and wellbeing of the service users. Object referencing and communication for service users with dementia or confusion has begun to be put up around the home to help service users orientate themselves in daily routines. Mealtimes have been reviewed offering two sittings making this a more pleasurable experience for service users. Service users during the key visit looked well groomed and clean. The atmosphere of the home had improved with an ambience that was relaxed and welcoming. The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 7 The lounge and dining area have been redecorated, a new carpet fitted has been here and to the hallways. New chairs and tables had been purchased. A visitor’s room has been set up on the basement floor. Crockery and glasses have been replaced. Radiators are being fitted with guards. The provider has undertaken a full review of the environment with the guidance of an Architect specialising in dementia care home design and is currently exploring the recommendations made to improve the home to meet the needs of those with dementia and cognitive disabilities. Hoists have been purchased for each floor to assist with moving and handling. Staff said they felt supported and were being given more opportunities for training since the acting manager had been at the home. The home’s last quality audit in August 2006 identified key areas that required urgent action and poor outcomes for service users and these have been included in the home’s improvement plan. What they could do better: Service users live in a home that would benefit greatly from an environment designed and equipped to promote their personal independence, safe freedom of movement and orientation around the home, with safe access and seating in the garden. Particularly for those with cognitive disabilities and dementia care. Service users would feel more secure if they had a statement of terms and conditions that explains the service provided. There are no contracts in place that detail the home’s and service users’ obligation in relation to the fees charged, a break down of fees, details of trial periods etc between the local authority funded service users and the provider. More robust medication practices and guidelines would greatly improve service users’ well - being and the safer administration of medication particularly in relation to correct administration and accountability with detailed written guidelines for PRN medication. Service users have been put at risk from incomplete recruitment procedures and checks. New POVA and Criminal Records Bureau checks and reference checks must be validated before staff start work at the home. The quality of lifestyle, care and choices for service users would be greatly improved through better communication systems and records of the action taken to address deficits in health care now recorded on the electronic format, by detailing the action taken to improve their care. The quality and lifestyle of service users would greatly improve through more choices of activities, to include outings to the local community and amenities. The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 8 Service users would benefit from staff undertaking more training in the care of those with dementia; care mapping and environmental triggers to aide their movement around the home. Staff would also benefit from core health and safety training related to their key roles plus being supported by structured regular supervision and appraisal. Service users would benefit from the replacing of bed linen, pillows and towels, replacing beds and some furniture and reviewing the dim lighting in bedrooms. This should be part of the home’s current improvement plan. The quality of care and management of the business would be enhanced further through rigorous monitoring by the provider and acting manager. Service users would benefit from alternative graphic formats of the service user guide being developed to assist them in selecting and remembering the home when choosing where to move. This would help further discussions with families and visiting staff to assist them in remembering and understanding where they are moving too and familiarity when arriving at the home. A thorough review of the current statement of purpose to give accurate information regarding the home’s services and facilities and current management arrangements, would be of benefit to relatives and service users in making a decision as to whether the home can meet their needs and expectations. 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 DS0000039813.V325057.R01.S.doc Version 5.2 Page 9 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 DS0000039813.V325057.R01.S.doc Version 5.2 Page 10 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): 1,2,3,4,6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Current information about the home does not accurately reflect the current services; facilities and management of the home to enable service users and their families make a decision as to whether the home can meet their individual needs. The home is not taking any new admissions at present as it is exceeding its current registration for the care of those with dementia or cognitive impairment. EVIDENCE: The home has developed a new statement of purpose (SOP) and service user guide (SUG). These need reviewing to ensure that they accurately reflect the home’s current registration and management arrangements. Both are in written formats that can be reproduced in larger font if required. Alternative The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 11 formats to include photographs/pictures should be explored to assist those with more visual information and prompts, particularly for those who are unable to visit the home and or have limited short-term memory. Discussion with the acting manager detailed exploration of a visual DVD and webpage to assist with sharing of information about the home but this has not yet been set up. Service users spoken with found it difficult to remember if anyone had visited them before moving in or getting a booklet telling them about the home. The owner stated all relatives were posted copies of the SOP & SUG. The home currently has 27 service users in residency with one service user in hospital at the time of the visit. As a result of concerns raised at a previous visit on 13th October 2006 the home was required to have all the service users’ cognitive ability assessed. The assessments show the home currently has 25 service users who have been assessed as having dementia or a cognitive impairment, thus taking them over their current registration by 11 placements. The remaining two service users have a learning disability. An immediate requirement was issued to the home and the provider has not admitted any new service users since the last inspection due to this. The local authority has also undertaken a number of reassessments of residents since the last inspection, although not all written reports have yet been received, one viewed evidenced a decline in a service user’s ability since the previous assessment. The Acting Manager stated a new assessment format has been devised covering all areas required by the standard and will be used when new admissions can be undertaken. New assessments could therefore not be tracked during this visit. A new electronic care plan format has been introduced and those tracked showed an improvement in the information of support and care to be given, with further records to assist in monitoring and reviewing of the health and welfare of the individual. Systems to communicate and monitor this information are still in their infancy and the inspectors discussed occasions where the information had not triggered action as would have been expected. Staff are also having to familiarise themselves with the systems to trigger the required action and reviewing of care plans. The gaps identified in staff training in core health and safety topics have been booked to take place over the next two months. The Priory gives all private service users a contract that is a statement of terms and conditions that clearly explain the service provided and not provided, the home’s obligation and the service user’s in relation to the fees charged, trial period, and terms of termination to protect both parties. There is a service contract between the home and local authority for locally funded service users, but there currently is no agreement of terms and conditions of residence with the service users/representative and owner directly. The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 12 However following the input of CSCI and after liaison with the local authority contracting department, contracts detailing terms and conditions between the provider and resident have been devised, agreed and have started to be distributed to local authority funded service users at the time this report was published. The home does not provide intermediate care. The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 13 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 poor. This judgement has been made using available evidence including a visit to this service. Service users have a new care plan system in place however these require more development to ensure good outcomes for service users. Understanding of individual dignity and respect is improving but is not yet consistent throughout the care and support provided. The home’s medication procedures have improved but do not yet sufficiently protect service users. EVIDENCE: A new electronic care plan format has been introduced and those tracked showed an improvement in the information of support and care to be given, with further records to assist in monitoring and reviewing of the health and welfare of the individual. Care plans case tracked evidenced that weight loss/gain is now being recorded and monitored weekly; the system introduced now triggers an alert if there is a high weight loss or gain recorded. Whereas The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 14 this progress is acknowledged, the system is in its infancy and did not evidence that the requisite action had been taken in some cases viewed. Service users were unable to reflect if they had discussed their care plan with staff. However after the site visit the provider supplied new information of a written review format with relatives and their views. The response indicated that care plans were amended where relatives did not agree but samples were not supplied to verify this actually occurred. There are now areas to record and track accident/incidents and falls. However these are new systems and some areas of the electronic format do not allow communication across sections and require further development of management tracking of records and recording action taken. Despite previous requirements being made regarding the assessment of risk the home has not yet implemented a ‘falls management programme’, it has however, set up a system to record incidents of falls and the time they occurred. The record was viewed and evidenced that a number of falls had occurred at the home since the last inspection some service users were noted to have suffered from a number of falls. The local dentist in Pembury is used when required, the optician ‘Vision Call’ is under contract, and the chiropodist attends 6 weekly and the hairdresser twice weekly. District nurse support continues for those requiring nursing care to pressure sores, ulcers etc. There has been an improvement in visual object referencing to orientate confused service users to assist them to find their way around their home. There was a continued lack of awareness as to the impact of the environment on already confused older people, for example in a number of service users’ bedrooms, calendars were seen opened on the wrong month or pages stuck together so they could not be opened and clocks had stopped and were not showing the correct time, in one shared room there was two clocks both showing the incorrect time. The privacy and dignity for service users has improved with staff considering service users’ preferences and these are being recorded in the care plan. Observations showed biscuits were being offered on plates, plastic beakers and plates have been replaced with glasses and crockery. The environment and furniture and fixings are slowly being upgraded and replaced through the home’s improvement plan, but there is still a lot of improvement required in this area. Dignity will be better managed for 4 service users whose bedrooms on the lower floor do not currently have access to a bathroom, when the new wet room is in use. There are plans to decommission one bedroom in the basement and make this a lounge alongside to the already refurbished visitor’s room on this floor. Screening is provided in all shared rooms. The curtain remained missing from one bedroom and in another the window was boarded up with hardboard. Service users’ clothing in a number of rooms was seen to be badly labelled by a black marker pen, the service user’s name had been The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 15 written in large bold writing that showed through the reverse of the garment, not only defacing the garment but showing little respect and dignity towards the individual service users. No staff members have undertaken training in new developments regarding equality and diversity. The medication room and records were inspected. The room continues to be inadequate in size and poorly ventilated, however, the acting manager advised that there are plans to provide ventilation via an extractor fan that can be taken through the adjoining toilet. The room had been cleared and de-cluttered since the last visit. The medication administration records were viewed and identified a number of gaps in records. The records did not evidence why some medication had not been administered. The signatures on the MAR sheets did not correlate with those on the approved administers sheet. Some admissions on the sheet were also confusing with 1 x weekly medication being signed for on consecutive days, it was not always possible to case track if the medication had been missed completely or administered and not signed for. There was no evidence that a monitoring system is in place, as the inspectors would have expected that these errors or omissions should have been noted by the home. There are no guidelines in place for PRN (as required) medications and some were noted to be given every day with no review recorded. The medication trolley was in need of a deep clean and medication pots were dirty and carried traces of medication that had been previously administered. There is a risk that these traces are being transferred onto other medication that services users are receiving. The medication policy was viewed and requires updating to include the correct staff titles and positions relating to the home, as this is misleading as it refers to first level nurses, for whom the home does not employ. The homes training matrix states 14 staff have undertaken medication training. The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 16 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 adequate. This judgement has been made using available evidence including a visit to this service. Service users are now being encouraged to make some choices about their daily lives. Further development is required of a programme of internal and external activities to meet personal interests. Service users have variety, choice and wholesome food, however service users could be at risk due to lack of basic food hygiene training and some poor practices. EVIDENCE: The pre inspection questionnaire received on 10th January 2006 stated a full time activities manager is in post, activities include partnership with local schools, churches, WI, luncheon club; cubs and scouts; exercise classes; entertainment and visits to local places of interest. On the day of the inspection a new activity co-ordinator was on supervised induction pending satisfactory recruitment checks. No other activity staff were in employment. A care plan for one service user who spent time in their room was tracked. It showed they liked to spend time in bed and to offer one to one time listening to music and to sit with quieter residents when in the lounge. Staff confirmed The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 17 that this service user was on bed rest during the day due to a pressure area care and District Nurse direction. They are permitted to be up for two hours a day and are encouraged to come down for lunch (this they were observed to do during this visit). However electronic daily records for a 6-week period only evidenced being supported to sit downstairs on five occasions and only one occasion where they were offered and enjoyed listening to their music, no one to one time was recorded. During both site visits service users in their rooms were observed to be visited by staff for daily living requirements such as food and drink, pressure area and personal care, at no time did staff spend individual time for company. A service user was observed to constantly call out and ask for staff to come and sit with them as staff went by. On one occasion a staff member did go to them but only for a few minutes stating they had work to do. Staff stated the service user also was on direction from District Nurses for bed rest due to their frailty, risk of falls and pressure area care. It was also stated that this service user did not like to watch television and rarely listened to music, there was no other stimulus in the room. It was noted that their call bell was out of reach. The music and movement sessions were booked for the following week and again in February. Service users seated in the lounges were seen to be relaxed and calm; those that were able to were wandering around the lounge and hallway with staff support and redirection. Outings were stated as being explored, through group and as well as one to one time but not currently being offered. Service users were observed to have nail care undertaken, listen to music and have the TV on in each lounge. Those visited in their rooms did not have TVs or radios on. Staff discussed how this was offered after lunch as many are sleeping during the morning as their personal care support has tired them. Some residents would like more independence than they have, and would benefit from further development to the environment to aid this and maintain their safety. A visitor’s room has been set up in the basement area and stated by the acting manager to be well used, especially at weekends. No one was observed to be using it during this visit. Bedrooms seen contained evidence that rooms can be and are personalised, service users are encouraged to bring items in to brighten up private bedrooms. The pre inspection questionnaire contained a list of 3 weekly menus offering choice and variety. However the lunchtime meal on offer during the visit did not correlate to any menu on display at the home or submitted with the preinspection questionnaire. A blackboard was on display detailing the meal choice for the day’s lunch. Meal times are stated as being breakfast 8.30 to 9.30; lunch 12.30 to 13.30; evening meal 17.30 to 18.30; supper 20.00 to 21.00. New mealtime routines had been set up with two seating times available. Staff felt this was working better. The dining room and lounge have been swopped over, and the dining area has been refurbished with seating for 20. A further 5 service users were seated at tables in the lounge area. Food The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 18 being served for the first sitting was observed to be served from a trolley covered with foil. This was observed to sit for over ten minutes waiting for the lift to arrive to take it to the service users and would have lost heat very quickly during this time. It was stated that a heated trolley was used for the main sitting. Plastic plates and beakers have been replaced with glasses and china crockery. Those spoken with were happy with the food offered and that alternatives were given when requested, such as an omelette. Food supplements were observed as being written up on MAR sheets but were not signed for on those case tracked. The acting manager stated they are exploring having a snack bar and alternative ways to enable service users to access hot and cold drinks as and when they wish too and where possible independently. There was a good stock of both frozen and fresh food at the home. It was noted that food storage in fridges was not compliant with basic food hygiene practice. Of the four catering staff, the training matrix detailed only one had completed food hygiene training and achieved the basic food hygiene certificate. The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence including a visit to this service. Protection from abuse will be better promoted through all staff having better understanding of poor practice, indicators of abuse and the support and confidence to follow any actions they may need to take. EVIDENCE: Copies of the complaint procedure are available on the home’s notice board. Due to the nature of the service and those service users living here, using this system can be limited. It was evident through discussion, a small proportion were clear about whom they would talk to if they were unhappy about something. Others due to their cognitive disability and not feeling confident they would be listened to, would require a relative or advocate to identify concerns and raise them on their behalf. The pre inspection questionnaire received on 10th January 2006 lists no complaints had been made since the last inspection. No formal written complaints had been made to the commission since the last inspection. Eleven service users have been admitted to A&E and there have been seven deaths at the home and three admissions to hospital in the past 12 months. Care plans seen are being redeveloped to assess and assist staff in elements of risk or guidance to manage imposed restraints to individuals due to their dementia, tendencies to wander, verbal and physical aggression and lack of The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 20 personal safety awareness. Risk assessments for identified risks had not been conducted during the random visit for environmental work being undertaken and infringing on service users’ personal safety and accessing the lounge and hall areas whilst new carpets were being laid The home does not manage service users’ finances. The home has had two adult protection investigations in the past 12months. The last was raised following the random inspection on 13th October 2006 and risks identified to service users during the visit. This is currently pending reassessment of the service users involved and monitoring by the local Social Services department. Immediate requirements were issued regarding service users’ safety following this visit. As detailed in this report improvements are beginning to be introduced by the new management but are not yet robust enough to provide consistent evidence through direct care case tracking and observations made from this visit. The training matrix details 17 of 30 staff having undertaken vulnerable adult protection training. The acting manager stated all remaining staff would complete this training over the coming months. This will also include in-depth learning in dementia care through a local distance learning college. The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 21 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): 19,20,21,22,23,24,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service and on the assurance that the outstanding work needed will be completed. Service users live in a home where maintenance is improving. They will benefit further and be safer through the completion of the environmental design and equipment proposed to promote their personal independence, safe freedom of movement and orientation around the home, with safe access and seating in the garden. EVIDENCE: Following the past two inspections and immediate requirements, the provider has instigated a detailed improvement plan to address the deficits in the environmental layout and design of the home in order to meet the needs of the service users, particularly those with cognitive impairments. It is acknowledged by the Commission that this is a long-term plan and work is still in progress. The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 22 An architect specialising in dementia care and design undertook an assessment in January 2007. The provider is currently considering the recommendations made. The Occupational Therapy assessment was undertaken over two years ago and it is recommended that this is reviewed in line with the architect’s report to ensure appropriate aides and adaptations are suitable particularly to individual rooms and needs. The previously gravelled drive has been replaced with tarmac, offering a flatter surface for those using wheelchairs and Zimmer frames. All external doors are fitted with security locks or alarms. There was some confusion as to which bell to push to gain access to the home, better signing would assist visitors. There has been redecoration of the lounge and new furnishings and furniture have been purchased, thereby offering a brighter and more comfortable area to relax. New carpet has been installed however during the random visit inspectors had serious concerns of the management of the fitting and the risk to service users’ safety. The dining areas have also been redecorated but furnishings remain the same. Orientation signs have been put up on toilets, bathrooms, the lift and service users’ bedroom doors. The garden and patio area cannot be safely accessed by service users. It is proposed that the patio doors are to be replaced to offer a flush fitting to the outside area and will have reinforced glass. Those currently in place present a hazard to service users, however, they have been recently toughened with a adhesive covering to prevent the glass shattering on impact. The acting manager and provider stated that service users will have full access to the garden by the summer of 2007. The garden is to be re-designed providing an easy access route from the home and it is hoped that there will be sensory aspects to the garden design to support those with a cognitive impairment. The designs shown to the inspector evidenced that the garden will be secure. Some wardrobes and chest of drawers in bedrooms have been replaced in bedrooms; however there were continued concerns over some wardrobes’ stability and safety, as also identified at the last visit. Lack of curtains to one bedroom window and general views over binned areas of the home are still of concern and stated by the acting manager to be in hand as part of the improvement plan. Old furnishings had been removed from outside aspects of two bedrooms, as identified in the random inspection. Paper towel dispensers and soap dispenser had been fitted to bedrooms, however old bars of soap remain, some were so old they showed signs of bacterial growth. Some of the decoration in service users’ private accommodation needs to be repaired as paint was seen to be flaking and there was damp staining on ceilings and walls. Lighting in many bedrooms was assessed as dim and of poor quality enhancing risk of disorientation, falls and injury. The acting manager stated a review of lighting is in hand as part of the improvement plan. The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 23 Stocks of bed linen, towels, pillows and blankets assessed during both visits show they are thin, threadbare and in need of replacement. The acting manager stated this is in the improvement plan to address. Beds assessed today are in need of replacement, due to broken drawers, poor quality and fitting mattresses and inappropriate height for safe personal care. The acting manager stated she has been reviewing this and working with one supplier to identify beds that would be suitable as part of the home’s improvement plan. The bedrooms in the basement will soon have access to a wet room that has been installed. At the time of this inspection it had not yet been commissioned for use. Proposals to decommission one bedroom in the basement for use as a quiet lounge will offer safer access to the wet room and promote better dignity with personal care. Radiators have been covered in the majority of personal bedrooms and corridors, some still requiring painting; two bathrooms/ WC’s were identified to remain uncovered. Problems with uneven and spongy flooring has been addressed through external contractors, however one particular floor still remained a concern but the manager had already identified this and the contractor was being recalled to look at this again. The visitor’s toilet has been converted into a sluice room. Racks for storage had not yet been fitted to promote good infection control and storage. This remains outstanding since the inspection in July 2006. A member of staff stated that visitors could now use the staff toilet on the top floor. The staff room has been moved to another floor, with lockable storage facilities in place. The boiler room had been cleared for the random inspection however during this visit the room had become cluttered with boxes, mattresses, Christmas trees, this is an identified fire hazard due to electrical fittings required for the water heating system. The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 24 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. Formal recruitment processes and checks have not been robust to date. New systems have been implemented but cannot be assessed as consistent at this stage. Service users are being supported by staff who are not receiving regular supervision to ensure service users rights and personal choices are respected and to ensure consistent care to be provided for service users. Further training in core health and safety will develop staff knowledge and understanding of their role and responsibilities. EVIDENCE: The records tracked evidenced poor recruitment procedure with shortfalls in recording and process being evident. Records of staff employed after the random inspection showed unsafe practice continuing, despite this being identified with the manager, of staff starting work without full satisfactory checks being undertaken and so putting service users at risk. The staff files assessed varied in their content. Some staff had not had an induction; this included new members of staff and existing staff who had changed their role to The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 25 undertake care. No contracts were in place to reflect the new role. New induction has been introduced and five staff records evidenced them beginning the skills for care induction. Records signed off showed new staff had been given a lot of information on one day to retain and understand. The acting manager has implemented new procedures in the past few weeks. One new staff member had been recently employed and was awaiting full checks to be completed; at the time of the inspection she was working fully supervised whilst these were outstanding. The standard recommending that supervision is given to care staff by their line manager at least 6 times a year, has still not been fully implemented. New staff were noted to have been given only one supervision session in a six month period. The pre inspection questionnaire received on 10th January 2007 lists 4 service users with high needs, 14 service users with medium needs and 9 service users with low needs. Seventeen staff has left service in the past 12 months, reasons listed were given as: 1 retired, 8 for personal reasons, 3 career changes and 5 to return to country of origin. Thirteen care staff are qualified to NVQ level 2 or above totalling 73 of care staff, which is a commendable proportion; 7 staff hold a current first aid certificate. The training matrix submitted as part of the pre inspection questionnaire identifies considerable gaps in core mandatory training. As detailed earlier in the report core health and safety training in key areas of role are not undertaken as a matter of course. I.E: food hygiene, COSHH and moving and handling. The acting manager stated training is booked over the next two months to address this. The training matrix key colours does not correlate with colours used and there are not dates of when training was undertaken or when refreshers are due, so making auditing and monitoring very difficult. During the course of the inspection some poor care and manual handling practices were observed and were brought to the acting manager’s attention. Rosters have developed to offer more accurate records of staff planned and who actually worked. There has been an introduction of a new 5am-11am and 5pm – 11pm shift to address core hours of personal care. Staff spoken with felt this has had a positive impact on their time for personal care and improved the support given. Direct observation showed better appearance of the service users since the random inspection and interaction from staff when given personal care, rather than rushing to move onto the next task. The statement of purpose states that there is six staff including day activities on shift in the morning and five in the afternoon to twenty-seven service users. Care staff rosters seen for week commencing 15th January showed this fluctuated The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 26 between 6 and 4 per shift including the 5-11 shift, with one less from 11am – 5 pm. The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 27 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. Service users at The Priory are beginning to benefit from having an experienced acting manager in place to take forward the home’s improvement plan, to ensure safeguards are in place for them. However, further work is required to evidence sustainability. The Priory owner has made a commitment to invest and support the improvement plan required to meet the needs of those with cognitive disabilities. EVIDENCE: The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 28 The current registered manager is on long-term sickness absence. The provider has transferred an experienced manager from another home owned by the company to take the home through its improvement plan. The acting manager has over 30 years experience in care of the elderly. Holding first level registered nurse qualification, ENB n111 specialising in dementia care, the Registered Managers award, NVQ Assessor award, ENB in intensive care and Care of the elderly and dying. Staff expressed how they felt things had improved since the acting manager’s transfer just before Christmas. As previously mentioned staff are not being regularly supervised. The pre inspection questionnaire received on 10th January 2007 records maintenance schedules and associated servicing and evidenced that all the required tests had been undertaken. A TV was noted not to have been portable appliance tested however and should be checked. Staff confirmed that new hoists were in place at the home but were reticent to their value and in discussing how often they actually used them. It was noted that the location of one hoist poses a trip hazard for services users as it is sited outside bedrooms and blocked the safe access to one. The inspector herself tripped over the stand; the provider was advised to move this asap. Staff undertake accident recording. Records seen evidenced a high proportion of accidents which were falls related. The new electronic care plan format has been introduced to record falls but currently this does not translate the information into a record that audit and tracks action taken. Allied with this is the requirement for consistency of basic care which highlights the need for more directive management within the home. The service users’ financial interests are safeguarded; the home does not manage any of their money. Deficits in the maintenance of the building include are identified in the environment section of this report and areas identified in the random inspection generated the improvement plan currently being worked through. Until the outstanding work has been completed the safety and quality of life for service users is affected. The doors leading to the passageways and stairs that open inward have had glass panels inserted to enable a clear view of anyone on the other side of the door; one door remains to be completed. All combustible items must be stored appropriately especially in storage cupboards where electrical equipment is located. This has been raised in past inspections and addressed for the random inspection but cluttered again for this last visit. It was noted that the cleaning trolley, containing hazardous materials, had been left unattended for some time. The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 29 The radiator in one basement bedroom was exceptional hot to touch and not guarded. Other rooms heating were very poor and the rooms were cold. The home uses a computer system linked to staff’s houses; the provider stated these had been made secure with a back up made for security. Quality assurance audits have taken place and have been compiled into an analysis by Laing and Buissin in August 2006. This report identified the same findings as the last inspection report dated July 2006 evidencing poor outcomes for service users in environmental design, safety and activities. From this the provider started to implement a development plan The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 30 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 2 2 1 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 1 2 2 2 2 2 2 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 1 The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 31 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 OP1 Regulation 6 (a,b) Requirement The registered person shall keep under review and where appropriate, revise the statement of purpose and service user guide and notify the Commission and service users of any such revision within 28 days. To be submitted to the Commission by the timescale date The registered person shall produce a service user guide to the care home, which shall include; details of the total fees payable and the arrangements for the payment of such a fee, arrangements for charging for any service additional to those mentioned above and a statement of whether any of the matters mentioned above would be different in circumstances where a service user’s care was being funded, in whole or in part, by a person other than the service user, in a standard form of contract for the provision of services and facilities by the registered provider to service DS0000039813.V325057.R01.S.doc Timescale for action 28/02/07 2 OP2 5 (1) (ba,bb,bc, bd,c) 28/02/07 The Priory Version 5.2 Page 32 users. Improvement plan to be submitted to the Commission by the timescale date. 3. OP7 13(4)(a)(c The registered person shall ) ensure that unnecessary risks to health and safety of service users are identified and so far as possible eliminated. This requirement remains ongoing and assessed as partially met with some progress being made. Improvement plan to be submitted to the Commission by the timescale date. 4. OP7 14(2)(b) 28/02/07 The registered person shall ensure that the assessment of the service user’s needs is revised at any time when it is necessary to do so having regard to any change of circumstances. An immediate requirement was issued at the random inspection on 13th October 2006 regarding this concern This requirement remains ongoing and assessed as partially met with some progress being made. Improvement plan to be submitted to the Commission by the timescale date. 5. OP9 13(2) The registered person shall make 28/02/07 arrangements for the recording, handling, safe keeping, safe administration and disposal of medication received into the care home. DS0000039813.V325057.R01.S.doc Version 5.2 Page 33 28/02/07 The Priory This is carried over from the last inspection. This requirement remains ongoing and assessed as un met with some progress being made since the last visit. Improvement plan to be submitted to the Commission by the timescale date. 6. OP10 12(4)(a) The registered person shall ensure that the care home is conducted in a manner, which respects the privacy and dignity of service users. Improvement plan to be submitted to the Commission by the timescale date. 28/02/07 7. OP12 12(3) 28/02/07 The registered person shall for the purpose of providing care to service users, and making proper provision for their health and welfare, so far as it is practicable ascertain and take into account their wishes and feelings. This is carried over from the last inspection and remains unmet. This requirement remains ongoing and assessed as partially met with some progress being made. Improvement plan to be submitted to the Commission by the timescale date. 8. OP19 23(2)(a,b, c,d) The registered person shall 28/02/07 having regard to the number and needs of the service users ensure that the physical design and layout of the premises to be DS0000039813.V325057.R01.S.doc Version 5.2 Page 34 The Priory used as the care home meet the needs of the service users; the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally; equipment provided at the care home for use by service users or persons who work at the care home is maintained in good working order; all parts of the home are kept reasonably decorated. This requirement remains ongoing and assessed as partially met with some progress being made. Improvement plan to be submitted to the Commission by the timescale date. 9. OP21 23(2)(j) 28/02/07 The registered person shall having regard to the number and needs of the service users ensure that there are provided at appropriate places sufficient numbers of baths and showers. This is carried over from the last inspection and remains ongoing. This requirement remains ongoing and assessed as partially met with some progress being made. Improvement plan to be submitted to the Commission by the timescale date. 10. OP22 16(2)(c) 23(2)(n) The registered person shall having regard to the size of the care home and the number of needs of the service users provide in rooms occupied by service users equipment suitable for the to the needs of the DS0000039813.V325057.R01.S.doc 28/02/07 The Priory Version 5.2 Page 35 service users and ensure that suitable adaptations equipment and facilities are provided. An immediate requirement was issued at the random inspection on 13th October 2006 regarding this concern In that recommendations of the occupational therapy assessment on 13/08/04 be reviewed and updated with a new and current assessment and recommendation are implemented. This requirement remains ongoing and assessed as partially met with some progress being made. Improvement plan to be submitted to the Commission by the timescale date. 11. OP25 13(4) (a,c) The registered person shall ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated in that radiator must be guarded or operate a low surface temperature. Electric heater in basement bedroom exceptionally hot and uncovered. Improvement plan to be submitted to the Commission by the timescale date. 12. OP38 13(5) The registered person shall make 28/02/07 suitable arrangements to provide a safe system for moving and handling service users. An immediate requirement was issued regarding this concern. DS0000039813.V325057.R01.S.doc Version 5.2 Page 36 28/02/07 The Priory An immediate requirement was issued at the random inspection on 13th October 2006 regarding this concern This requirement remains ongoing and assessed as partially met with some progress being made. Improvement plan to be submitted to the Commission by the timescale date. 13. OP22 23(n) The registered person shall ensure such equipment as many be required are provided for service users. In that all call bells are maintained in working order and made accessible to the service users at all times. This requirement remains ongoing and assessed as partially met with some progress being made. Improvement plan to be submitted to the Commission by the timescale date. 28/02/07 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 OP1 Good Practice Recommendations It is recommended that alternative methods be explored to assist service user with cognitive disabilities with information about the home. Such as more visual representation, in photographic, DVD recorded or web cam systems. DS0000039813.V325057.R01.S.doc Version 5.2 Page 37 The Priory 2 OP15 3 OP33 It is strongly recommended that hostess trolley be purchased to transport food for the first sitting of mealtimes and so eliminate food going cold whilst being transported to service users. It is strongly recommended that the policies and procedures are reviewed to ensure correct titles and descriptions match those used by the home. It is strongly recommended that service users and if appropriate representatives have the opportunity to help maintain their personal records. Assessed as an ongoing process with the introduction of new care planning format. 4 OP37 The Priory DS0000039813.V325057.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 DS0000039813.V325057.R01.S.doc Version 5.2 Page 39 - 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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