Inspection on 02/03/07 for The Priory

This inspection was carried out on 2nd March 2007.

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 11/12/06

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 Mr Keith Salmon Key Unannounced Inspection 2nd March 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Priory DS0000064067.V332033.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.V332033.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 thepriory@talktalkbusiness.net 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 vacant post Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places The Priory DS0000064067.V332033.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 iin 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, 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. 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 registered to provide care for a maximum of 37 residents of whom up to 17 require nursing 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. The Priory DS0000064067.V332033.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 9.30am, concluded at 2.30pm (a total 5 hours) was conducted by Mr Keith Salmon and undertaken as a follow-up to the ‘Key’ Unannounced Inspection, carried out on 11 December 2006 and a management review meeting held on 31 December 2006 at the Shrewsbury Office, between Mr. Pritpal Singh, the Owner/Responsible Person, Ms. Kay Davies (new Manager), Mr. Brian Lock Regulation Manager (CSCI), Mr. Joe O’Connor (Central Registration CSCI) and Keith Salmon. Ms. Kay Davies was present for the Home throughout the Inspection. At the ‘Key’ Inspection held in December the Inspector found that, whilst some progress had been made in response to the previous ‘Key’ Inspection, undertaken during October 2006, (e.g. redecoration, replacement of ceiling tiles, installation of new radiator covers), concern remained regarding lack of improvement in some critical areas, including:- staffing levels, problems with laundry provision. As a consequence it was decided to undertake a further ‘Key’ Inspection early in 2007, but allowing sufficiently elapsed time to enable the newly appointed Manager to begin to effect change. 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. The Inspector held 1:1 discussions with the Manager, 8 Residents, 2 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 from reports of CSCI Inspections immediately preceding this one, give a very clear indication The Priory has been 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”. This is reflected in comments made during the Regulation 26 Unannounced Visit (by the Responsible Person’s Agent) – these included… “I am treated kindly and respectfully” … “I am very happy with all aspects of care - they all work very well” …”Nothing seems to be any bother for them” …“The care here is very good. I could not ask for anything more. We are all treated like a big family – I feel very happy living The Priory DS0000064067.V332033.R01.S.doc Version 5.2 Page 6 here” …“We now have activities which we did not have before…I look forward to the sessions”. These, and other positive comments, were reiterated to the Inspector in conversation with the same Residents and the two visitors present during the Inspection 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.V332033.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.V332033.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Processes to ensure appropriate, and thorough, care needs assessment are effectively applied prior to admission, thus enabling the Manager to make an informed decision regarding the Home’s capability in meeting the individual care needs of prospective Residents. EVIDENCE: A ‘Requirement’ from the previous Inspection was “The Responsible Person must ensure that for all prospective Residents, a pre-admission assessment is undertaken by a suitably trained/ experienced member of staff, and written evidence retained within the Residents care planning documentation.” ‘Case Tracking’, which involved a full review of four Residents’ Care Plans/Files was conducted. These were randomly selected and included two from the ‘Nursing’ Section’ and two from the ‘Residential’. This review demonstrated suitably experienced Staff assess care needs of all potential Residents, prior to making a decision as to whether the Home can successfully meet those needs, The Priory DS0000064067.V332033.R01.S.doc Version 5.2 Page 9 and before accepting the prospective Resident for admission to the Home. The ‘Requirement’ relating to this ‘outcome’ area has been met. The Priory DS0000064067.V332033.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The model of Care Plan utilised by the Home is of a comprehensive design, easy to follow and utilised well by Staff as a central part of meeting the Residents’ assessed care needs. Care is delivered considerately and effectively. The storage, administration, and disposal of medicines are in accordance with accepted good practice. EVIDENCE: A ‘Requirement’ from the previous Inspection was “The Manager must ensure that the change over to the new model of Care Plan is completed as soon as possible.” As a component part of the ‘Case Tracking’ exercise the Inspector found all Care Plans have now been transferred to the new format. The Priory DS0000064067.V332033.R01.S.doc Version 5.2 Page 11 Care Plans inspected in detail presented as well organised, easily understood and demonstrated Evidence of regular review and current entries Involvement of SU/Relative/Advocate. Evidence of ‘Risk Assessment’ Development of specific care planning where relevant. The ‘Requirement’ relating to this ‘care group’ has been met. A Review was undertaken of the policies/procedures relating to the management/administration of medicines, i.e. records relating to the supply, storage and disposal of medicines, including records of ambient and Medicine Room temperatures, together with records of the administration of medicines, all of which demonstrated the Home’s management/administration of medicines is in accordance with accepted good practice. The Priory DS0000064067.V332033.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A good range of leisure opportunities, consistent with Residents’ capabilities, is provided. The Home facilitates achievement of desired lifestyle through Residents conducting 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 improvement in the variety and quality of meals noted at the previous Inspection has been maintained. EVIDENCE: A ‘Requirement’ from the previous inspection was “The activities programme is to be reviewed and extended to include availability of outdoor trips etc and to take account of Service Users’ wishes.” Since that time one member of Care staff, designated ‘Activity Coordinator’, has taken on specific responsibility for planning and managing leisure/social The Priory DS0000064067.V332033.R01.S.doc Version 5.2 Page 13 activities. To enable this to be achievable 16 hours a week have been specifically set aside for this task. Evidence was observed suggesting this new post is already having a positive impact with increased incidence, and improving range, of social and leisure activities available to Residents. During February activities offered to Residents included – a ‘Beetle Drive’, Bingo, craft work in preparation for Easter (i.e. Easter cards, eggs, and bonnets), and entertainment by a Japanese musician. An ‘Activities Programme’ for March has been posted on the central notice board and is set to include – video afternoons, escorted walks in town, exercise sessions, musical entertainment (an outside entertainer) and traditional board games (‘Ludo’, dominoes, ‘snakes and ladders’). Events are also planned to celebrate St. Patrick’s Day and Mother’s Day. The Home is also arranging a visit, during April, to see a production of Cole Porter’s ‘Anything Goes’ for Residents (and Relatives) who may be interested. The allocation of staff hours, published programme, and comments by Residents and Visitors, have provided firm evidence the previous shortfall in provision of social and leisure activities has been very effectively addressed. In the view of the Inspector the above ‘Requirement’ is now met. Several Residents commented they liked the food provided, with one adding there had been an improvement some months ago and this had been maintained. The Priory DS0000064067.V332033.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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.V332033.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most areas of the Home have shown marked improvement in décor/ refurbishment and there is now satisfactory dining space provision serving the ‘Residential’ part of the Home. However, Residents may still be at risk from cross infection due to inadequate laundry provision. The Home is generally clean and hygienic. EVIDENCE: At the previous Inspection, and those immediately preceding, several ‘Requirements’ were issued under this ‘Outcome Area’. These covered various shortfalls affecting the general safety and well-being of Service Users, particularly given that The Priory has a client group who require nursing care. The Priory DS0000064067.V332033.R01.S.doc Version 5.2 Page 16 Specific areas requiring concerted action were:Long term refurbishment/redecoration plans for the Home. The provision of sufficient dining room(s). ‘Out of use’ bathrooms to be brought back into use including the repair or replacement of two damaged ‘Parker baths. Progress to be made in increasing the capacity for the laundering of bed linen and Service Users personal clothing. Redecoration programme - With regard to this ‘Requirement’ a written programme has not, as yet, been provided to the CSCI. However, redecoration and refurbishment has continued at a reasonable pace with much of the Home having been redecorated, including the replacement of a further number of new, and attractive, radiator covers. It is expected the remaining ‘old style’ covers will be replaced by the Home’s Maintenance Man over the coming months. Although it is accepted that some good progress has been made in respect of redecoration the ‘Requirement’ relating to the provision of to CSCI of planned works will remain in force. At the previous Inspection the Inspector found the room previously used as the lounge had been converted into the main dining room and the lounge, in turn, had been recreated in the adjacent room, which offers better views to the front of the house and has the added facility of closer proximity to a toilet. The Manager and staff feel that although this represents an improvement over the previous arrangement, further changes will be necessary to gain full potential from the change. Additional proposals include the purchase of circular dining tables and new chairs and improvements to lighting in the lounge. A further, more radical proposal, is to remove part of the internal wall separating the two rooms, to offer a more interesting combined space, which would afford greater flexibility of use. All of the above activity provides a welcome indication 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. Laundry provision - A ‘Requirement’ from the previous Inspections was The Responsible Person must send to CSCI for approval plans for increasing the capacity for the laundering of bed linen and Service Users’ personal clothing.” At the date of this Inspection CSCI had not received any written proposals or plans for approval aimed at meeting this ‘Requirement’, which has remained The Priory DS0000064067.V332033.R01.S.doc Version 5.2 Page 17 outstanding for several Inspections. However, inspection of the laundry demonstrated that, whilst there has been no action in respect of the development of laundry services, the new Manager has taken steps to improve practices, albeit within the constraints of the existing facility. This has eased the situation whereby soiled laundry was ‘stored’ whilst awaiting weekly collection by an outside laundry service. This has been achieved by cessation of that contract and for all laundry to be processed, in the Home, on a daily basis. At the previous Inspection a Requirement was cited which related to control of access to the laundry room, i.e. “The Registered Person must ensure that a lock is provided to the laundry door, to prevent access by Residents when the laundry room is unattended.” It was found there is still no permanent facility for locking the laundry, and being accessible to passing Residents, some of whom have dementia related illness, this presents a serious health and safety hazard. In order to protect Residents, as agreed at the previous Inspection, and as an emergency and temporary measure only, a ‘high level’ bolt has been fixed to the laundry room door. It will remain a ‘Requirement’ that the Home is to fit a permanent lock to the laundry door without further delay. It should be reported the new Manager has introduced revised practices in respect of the use of detergent (a measured/closed dose system has been introduced) and has improved safety both for Residents, and Staff, to a satisfactory level. Whilst it is accepted these measures are useful interim arrangements, comments made in earlier Reports, and the immediately preceding ‘Key’ Inspection Report, are reiterated i.e. the capacity of the laundry is of serious concern, particularly at peak periods of activity in that the laundry room does not offer adequate floor space for the reception, sorting and onward management of linen and clothing. 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. At the time of the previous Inspection the plan to re-provide the laundry facility was to relocate it to an existing ground floor bathroom located in the original part of the Home. That proposal included ‘knocking through’ the wall into the adjacent storeroom thus providing a larger area. The Priory DS0000064067.V332033.R01.S.doc Version 5.2 Page 18 The main disadvantage of this would be the potential loss of a bathroom facility. Since that time technical problems (building works, health and safety) have led to a re-appraisal of possible solutions and the Inspector was informed the Responsible Person is seeking ‘quotations’ based on extending the existing laundry room outwards onto spare land at the rear of the building. Whilst the Inspector has no objections to this proposal in itself, there will remain a ‘Requirement’ for detailed plans to be agreed by CSCI prior to commencement of any building works. Bathing facilities - A ‘Requirement’ from the previous inspection was: “The Responsible Person must ensure the two damaged baths are repaired or replaced and the bathrooms brought back into use.” The Inspector found that two of the Home’s bathrooms remain out of use due to faulty baths, which are awaiting repair/replacement. At the previous Inspection the Inspector was informed two ‘Parker’ Baths were on order and were to be delivered in the near future, i.e. by the end of February 2007. This plan has not been realised. However, there are now revised proposals to address the matter of providing satisfactory bathing arrangements for Residents. These comprise:Conversion of the ground floor ‘Parker’ bathroom to a shower/’wetroom’. Transfer of the ‘Parker’ bath from the ground floor bathroom to the first floor bathroom. Whilst the Inspector supports both of these proposals, he considers the improvement to the upstairs facility to be the most urgent and should, therefore, be scheduled as ‘priority’. Residents from the first floor are currently required to bathe in one of the ground floor bathrooms, which is an unacceptable situation. Therefore, if work on both bathrooms cannot be conducted concurrently, which is the preferred option, then the transfer of the Parker Bath to the first-floor bathroom is to take precedence. Therefore, the ‘Requirement’ relating to the repair/replacement provision of baths will remain in force. During conversations with Residents and Relatives the Inspector was made aware there is a problem in ensuring a reliable supply of hot water to the wash hand basins in some of the bedrooms on the first floor in the original part of the building. It is new ‘Requirement’ this matter is investigated by the Manager and remedial action taken. The Priory DS0000064067.V332033.R01.S.doc Version 5.2 Page 19 More positively, a small, but significant, indicator that important changes are being wrought, has been the recent purchase of new cups and saucers, with the plan to replace all crockery with the same design. Looking across the whole spectrum of this group of ‘Environment’ related outcomes and, notwithstanding the need to completely meet all Requirements, the Inspector considers there is sufficient indication of change to warrant movement from a rating of ‘Poor’ to one of ‘Adequate’. Should the plans made known to the Inspector come to fruition within a reasonable period of time there may be the possibility of further upwards movement to a higher rating. The Priory DS0000064067.V332033.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. Staff numbers and skill-mix listed on the staff rota are now sufficient to meet the assessed care needs of current Residents. Recruitment and employment practices are consistent with the safeguarding of Residents. The commitment of the Home to providing training for Care Staff shows signs of improvement. EVIDENCE: A ‘Requirement’ from the previous Inspection was “The Registered Person must ensure staffing levels, and skill-mix are in accordance with the ‘Conditions of Service’.” Previous target date (06/07/06) unmet. The new Manager has addressed this shortfall vigorously, and effectively, through a combination of recruitment of additional staff (one RGN, two Care Staff, and one Domestic Staff member) and to ensure the Staffing Notice was met, through the occasional use of Agency Staff, when necessary. The current staffing rota, and those from the immediately preceding weeks, were examined and found to comply with the Staffing Notice. This ’Requirement’ is met. The Priory DS0000064067.V332033.R01.S.doc Version 5.2 Page 21 At the previous Inspection the Inspector reported that the on-going provision of training for Care Staff, in accordance with individual Staff Member’s learning needs, had declined and was currently only satisfactory. This particularly related to training, specifically ‘lifting and handling’, ‘fire safety’, ‘adult protection.’ As a result a ‘Requirement’ was issued “The Responsible Person must ensure all staff receive training opportunities which enable them to meet the changing needs of the Residents.” At this Inspection discussion with the Manager, and staff members, plus review of a forthcoming programme of training for staff in respect of these areas, evidenced the issue is being addressed. The training programme commences on 13 March 2007 and extends through April and May 2007. This reflects a positive step forward and, whilst, at the time of this Inspection, training had not commenced, therefore not possible to move the rating beyond ‘adequate’, the signs of improvement in respect of staff training is encouraging. The ‘Requirement’ will remain in place for the time being. Also the proportion of Care Staff who have attained NVQ level II (or better), at the time of the Inspection, was found to be at 53 of Care Staff thus meeting the 50 target. This figure includes 8 staff who have attained NVQ Level III. The Priory DS0000064067.V332033.R01.S.doc Version 5.2 Page 22 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, & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The new Manager (Ms Kay Davies) has made an effective impact in relation to day-to-day management, strategic planning, and staff morale. Residents now live in a safer environment. Continuation of the perceived improvement should lead eventually to a higher rating. EVIDENCE: At previous successive Inspections a number of ‘Requirements’, relating to this ‘Outcome Group’, were cited, and which remained outstanding for a considerable period of time. These shortfalls related to strategic planning, management, organisation, and ethos within the Home, and which, in turn, had a detrimental effect on the safety and morale of Residents and Staff. The Priory DS0000064067.V332033.R01.S.doc Version 5.2 Page 23 However, at this Inspection it was evident there had been positive movement in these areas, and the Inspector is pleased to report as to the present situation with regard to these ‘Requirements’ – 1. “The Acting Care Manager must make application to the CSCI to be approved as Registered Matron/Manager.” Previous target date (09/07/06) unmet. Since that time Ms. Kay Davies has been appointed Manager and has made application to the CSCI to become ‘Registered Manager. This ‘Requirement is met. 2. “The Registered Person must visit the Home and submit related reports of the visits in accordance with Regulation 26.” Since the previous Inspection the Responsible Person (Mr. Pritpal Singh) has appointed an Agent to undertaken monthly ‘Regulation 26’ visits in his stead. The Inspector observed written evidence of two visits since December 2006. These were found to comprehensively address aspects of care provision, were clearly written and to reflect the improvements noted by the Inspector. This ‘Requirement’ is met. 3. “The Registered 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. This Requirement was discussed with the new Manager. However, given that only 2 months have elapsed since her taking up post it is accepted this particular ‘Requirement’ is yet to receive attention whilst other issues are being addressed. Therefore, this ‘Requirement’ will remain and the Inspector is assured it will receive full attention in the near future. 4. “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.” A permanent lock has now been fitted to the laundry room door with keys carried by the Laundress, and the Senior Nurse on duty. This ‘Requirement’ is met. The Priory DS0000064067.V332033.R01.S.doc Version 5.2 Page 24 5. “The Responsible Person must provide suitable changing room accommodation for catering staff.” Catering Staff are now changing in the newly created Staff Room. This is a temporary measure whilst a more permanent venue is determined. The Inspector accepts this arrangement as satisfactory and the ‘Requirement’ is met. With regard to Key Standard 35, The Priory does not manage Residents’ personal monies. In summary, management of the Home is now showing marked improvement. Staff informed the Inspector they are much more settled particularly appreciating the more structured way in which their hours are allocated, i.e. they are better informed about as to their required work pattern and can plan their lives accordingly. In support of this the Home now has a monthly newsletter aimed at Residents, Visitors, and Staff. Although Kay Davies has only been in post for only a few weeks many aspects of the Management process have been speedily and effectively addressed – some of which had been outstanding ‘Requirements’ for some time, e.g. transfer of care planning documentation, staff training provision, better use of available rooms, progress with plans for redecoration/refurbishment. Whilst there remains considerable further planning, and completion of plans to ensure improvement in the quality of service provided for Residents, the Inspector feels improvements achieved to date lends encouragement for the future. The Priory DS0000064067.V332033.R01.S.doc Version 5.2 Page 25 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X N/A X X 2 The Priory DS0000064067.V332033.R01.S.doc Version 5.2 Page 26 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 OP19 Regulation 23. (2)(b)(d) Requirement The Responsible Person must provide the CSCI with a plan for redecoration/refurbishment, together with a programme, which includes dates for commencement and completion of remaining work. The Responsible Person must ensure that work to convert the ground floor bathroom into a wet-room is completed, and the facility brought into use as soon as possible. Timescale for action 30/04/07 2. OP21 23. – (2)(j) 30/04/07 3. OP21 23. – (2)(j) The Responsible Person must 15/04/07 ensure the damaged bath in the first floor bathroom is repaired or replaced and the bathroom brought back into use. The Responsible Person must 31/03/07 ensure a review of the reliability of hot water supply to bedrooms, on the first floor in the original part of the building, and to take remedial action to ensure a supply of the same. 4. OP21 23. – (2)(j) The Priory DS0000064067.V332033.R01.S.doc Version 5.2 Page 27 5. OP26 16.(2)(e)(f) 6. OP30 18.- (1) (c)(i)(ii) The Responsible Person must send to the CSCI, for approval by the Inspector, detailed 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 that all staff receive training opportunities which enable them to meet the changing needs of the Residents 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. 30/04/07 30/04/07 7. OP33 24 (1) (a) and (b) 30/04/07 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 OP19 Good Practice Recommendations It is Recommended that the current laundering capacity be increased by an additional washing machine, and an additional drying machine. The Priory DS0000064067.V332033.R01.S.doc Version 5.2 Page 28 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.V332033.R01.S.doc Version 5.2 Page 29 - 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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