Inspection on 20/07/06 for The Priory

This inspection was carried out on 20th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 18/01/07

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 Maria Tucker Key Unannounced Inspection 20th & 23rd July 2006 09:15 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.V301500.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.V301500.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 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.V301500.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th March 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. The home is under new ownership having been purchased 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, staff 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 upwards and chiropody £15.60 weekly as required. The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection in the year running from April 1st 2006. As part of the inspection process two site visits were carried out. The first on Thursday 20th July 2006 lasted from 09:15 to 17:15pm with Regulatory Inspectors Maria Tucker and Lynnette Gajjar. The second visit on Sunday 23rd July lasted from 17:15pm to 19.15pm by Regulatory Inspectors Maria Tucker and Ann Block. The home currently has 29 people in residence with 1 service user in hospital. The visit was spent talking directly with some service users and visitors privately and collectively, care and ancillary staff, the manager, area manager and provider. 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, visitors and observation followed by discussion with care staff, follow up calls to health professionals and care managers and evidencing records held at the home. A tour of part of the premises was undertaken, with time spent assessing various records held in the home. Information was also gathered through a pre inspection questionnaire completed by the manager and comment cards returned to the Commission. A number of CSCI “comment cards” (questionnaires) were sent out to relatives and professionals involved in the home. Those returned included: 4 Comment cards were received from visitors / relatives “My (service user) is always clean and tidy, she has her hair cut, permed and coloured regularly, sometimes her nails are manicured and painted. She has a good rapport with the staff and is generally very happy”. “(Service users name) has been at the home for two weeks and so far we are very happy with the care and attention she is given the staff are kind’’. ‘‘(Service user) is always looking nice, with their hair done and make up on. There is always a nice feel about The Priory when you walk in”. 1 health professional comment card was received. Eight ‘Have your say’ comment cards were received from service users. Comments included: “Very happy with care received” The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 6 “On occasions requests or recommendations are not always actioned” What the service does well: What has improved since the last inspection? The home has begun to engage service users more in activities in the home including exercise offered by an external staff. The full time activity coordinator employed prior to the last inspection has begun to formalise activities and vary what is on offer. There has been an assessment made by the infection control nurse with many of the recommendations promptly acted upon including a sluice facility. The recommendations from the CSCI pharmacist have mostly been acted upon. The local pharmacy has visited and offered support and advice. Training has been made a priority with more training available and future training planned. The atmosphere in the home was vibrant, busy and overall relaxed. Staff were approachable and some good interactions were noted between staff and service users. The appointment of a manager has provided stability and formal management arrangements. The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 7 The laundry room and laundering of clothes has vastly improved. Quality assurance audits have taken place and have been compiled into an analysis. What they could do better: The admission process needs to be made more robust with full assessments made by the home with relatives and service users with inclusion of evidence that needs can be met in the home. Prospective service users and their families need to be given a statement of purpose and a service user’s guide prior to moving into the home and have a contract issued to evidence their rights as consumers. The process for service users’ assessment of their suitability for moving or continuing to remain in a shared room needs to reflect the home’s policy for shared rooms, this is particularly relevant as the home cares for a number of people with dementia. The care plans, risk assessments and guidelines for support for service users is not detailed enough in needs, choices or assistance required and cannot evidence that consistent individualised care is provided. Service users and relatives must be included and involved in this process. The monitoring of health and welfare must be followed through as set out in the care plan with action taken as identified. The medication procedure needs to be firmed up and the storage room cleared to ensure medication is stored and administered as per professional guidelines. Object referencing and communication for service users with dementia or confusion should be put in place to orientate service users in daily routines and with maximising choice. The privacy and dignity of service users should be considered fully and action taken to promote this area, this should include the provision of a visitor’s room. The environment must be made safe and kept well maintained. Service users live in a home that would benefit further 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. To evidence that service users have suitable staff caring for them in sufficient numbers, the policy and procedure for the recruitment of staff must be adhered to and an accurate staff rota maintained. The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Priory DS0000039813.V301500.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.V301500.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6 The quality in this outcome area was poor. This judgement has been made using available evidence including a visit to this service. Current written information provided by the home does not enable service users and representatives to make informed decisions as to whether the home can best meet their individual needs. Service users who share rooms have not had an accurate assessment as to their suitability or best interest. Service users cannot expect to have a complete needs assessment or contractual arrangements agreed prior to moving in. EVIDENCE: An updated version of the Statement Of Purpose was given to the inspector during the site visit and briefly discussed with the Provider. Omitted are the relevant qualifications (the qualifications listed are abbreviated) and the experience of the registered provider; the organisational structure of the care home; the criteria for admitting to a shared room and correct contact details for the commission. The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 11 The pre inspection questionnaire received on 16th May 2006 lists 12 admissions and 2 discharges in the last 12 months. The provider stated that service users who are placed by the local authority have a contract direct with the home from the local authority. A blank contract was seen contained in the service user’s guide in 2 service users’ rooms, this document was stated by the manager to be given to all service users. The provider stated that the contract was used for private funded service users only. Section 9 acceptance of agreement identifies the room, weekly fee, name of service user, representative and relationship name and signature for fee payment. An assessment of a service user who had been admitted to a shared room was viewed. The home had conducted an assessment prior to offering a place. Senior staff had visited the service user at their place of current residence there was no evidence that family or next of kin had been consulted. A health assessment that formed part of the assessment process was contained in the file. The assessment conducted by staff did not have each section completed. The assessment format used by the home (a copy of which was given to the inspector during the site visit) omitted sections covering personal care, history of falls, cognition, social interests, hobbies, religious and cultural needs and personal safety as identified in standard 3.3. The assessment as to the suitability of a shared room had been made although documentations were not able to be located. The health assessment evidenced non-compatibility as per the home’s criteria for shared room as stated in their policy and procedure for admitting service users to shared rooms. The service user was privately funded; a copy of the contract was unavailable as this was stated as being processed by the administration officer. The service user or family were not given a copy of the statement of purpose or service user’s guide or contract before moving in. The manager said they had been given a brochure of the home, however, this does not contain all the required detail of services and facilities and made statements which could not be verified in practice. The option of a single or double room was not discussed with the family or service user prior to moving in. The manager stated a single is always offered when one becomes available. The home does not provide intermediate care. The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, The quality in this outcome area was poor. This judgement has been made using available evidence including a visit to this service. Care plans, risk assessments and guidelines do not hold detailed information to ensure consistent approaches by staff to meet the individual health and social care needs of service users and track that assessed care is provided. Service users cannot reliably expect to be treated with dignity or respect. The home’s medication procedures do not sufficiently protect service users. EVIDENCE: Feedback from relatives included “My (service user) is always clean and tidy she has her hair cut, permed and coloured regularly sometimes her nails are manicured and painted. She has a good rapport with the staff and is generally very happy”. A relative spoken with commented their relative was “So well looked after and happy”, and that the staff were very good. The pre inspection questionnaire received on 16th May 2006 lists 2 service users as having pressure sores (both from hospital), details of arrangements for accessing health professionals i.e. “We do have an urgent GP visits on Thursdays”. The local dentist in Pembury is used when required, the optician The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 13 is ‘Vision Call’ under contract, the chiropodist attends 6 weekly and the hairdresser twice weekly. Two service users case tracked evidenced weight loss; nutritional assessments had been completed but indicated low risk. Weight had not been monitored weekly as instructed in the care plan. There was no evidence that advice had been sought regarding nutritional needs or weight losses. There was no record of monitoring of falls or action taken to reduce the risk, few formal risk assessments had been undertaken. One service user had had 6 falls in the last month, their care plan recorded no changes, amendments or action having been taken to reflect this. Overall the care plans covered basic care elements required. They did not consider the needs of service users with dementia i.e. behaviour was not assessed or guidance provided to support inappropriate behaviour, specialist support or assistance with meals, personal care or social interaction. Care plans were not personalised and records tracked evidenced that the care as assessed was not being provided. Large gaps in records were identified with poor brief daily write-ups. There was no indication or evidence that relatives or service users had been involved in the care planning process. Health monitoring was limited although chiropodist and district nurse services were regularly used. There was no evidence of communication or object referencing to orientate confused service users for daily routines or to assist them to find their way around their environment. There was a lack of awareness as to the impact of the environment on already confused older people, for example the service users’ daily notice board had the wrong date on it. During the first site visit a motivation physical exercise session was taking place with service users encouraged to take part. The privacy and dignity for service users was compromised, as care was not individual, service users preferences were not considered or reflected within the care plan. The environment and furniture and fixings further compounded this with incontinence aids on chairs, mismatched and broken furnishings and in many cases heavy and difficult to open drawers and doors. Items such as benches in the grounds that had been donated in memory of service users were used by staff. Zimmer frames and sticks were left in rooms rather than being readily available to the service users. Dignity is further compromised by the continued use of the three basement rooms for 4 service users who have do not have access on that floor to a bathroom and are isolated in a predominantly staff based area (kitchen, food & equipment storage and staff room). In a shared room the curtain provided for screening was missing. In another bedroom there was no curtain at the window. The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 14 A service user in their room was in their chair during both site visits. A manual handling belt was noted to be around their waste, there was no call bell in reach, the manager stated they were unable to use this although this had not been recorded in the care plan. Staff were observed to be popping in and out with drinks and tending to care needs during one of the visits. At the second site visit this service user was seated in their chair in clothes that did not fit with food on the floor, a drink out of arm’s reach and an empty medication pot. A service user who was in bed unwell during the site visits commented that they were “Feeling rough do not feel good”. During the second site visit those service users who were in their room or in bed were stated to be in need of bed rest. The pre inspection questionnaire received on 16th May 2006 lists 14 service users with dementia; 23 service users who were incontinent; 5 service users who were doubly incontinent; no wheel chair users, no service users exhibiting extreme behaviour; 21 service users requiring assistance with dressing / undressing; 5 service users assistance required with meals; 30 service users require assistance with washing / bathing; 26 service users requiring assistance with toileting; 3 service users requiring 2 staff assistance day and night; 2 service users with hearing impairments and 6 with visual impairments. The medication room has had a sink fitted although there was no liquid soap to hand or towel dispenser fitted to the wall. It remains cramped with items stored such as a raffle prize, which reduces the available space further. The district nurses use this room for storage of dressings. The temperature of the medication room was 28.1 and 30 degrees respectively for each inspection according to the thermometer. It should not exceed 25 degrees. There was a fan in the room. It should be considered if this room is suitable as being fit for purpose. The arrangements of the clinical room and a procedure for the administration and recording of non-prescription homely remedies, (if used), were identified by the CSCI pharmacy inspector. Staff stated that some service users are seen outside of this room and have dressings changed as they choose not to go to their private accommodation. The medical room is situated in a thoroughfare to the toilet, which is next door, and bedrooms. A service user was sitting outside of medical room waiting for the district nurse to visit for treatment as their preference was to be seen there as stated. When asked if they see the nurse in their room “No I’ll sit here and wait”. There is a lockable medication fridge with items stored appropriately. The medication administration records on the whole were accurate although some signatures for eye drops had not been made. A tablet was seen to be on the floor in a service user’s bedroom, another service user’s bedroom had an The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 15 empty medication pot on the table. The manager stated that they were aware that the service user where the medication was found on the floor had a problem with taking medication but no record of necessary action had been taken. It was discussed that a ‘as required’ medication policy and procedure needs to be reviewed and improved upon as they are currently recorded in the medication administration record sheets as ‘as directed’. There needs to be some way of recording what and when the medication has been prescribed as being needed as per GP guidance. For identification purposes the home have an identity sheet at the front with a photograph and name of the service user. Again this was discussed that this would provide a good place to record other details such as preferred name, or any special requirements relating to medication i.e. if there is a preference for drinks when taking medication. Staff receive training in medication administration prior to undertaking this task. A recent medication safe handling training was conducted. Staff are awaiting the certificate of 5 units in safe handling of medication books to be signed off following successful completion. The manager stated that a staff member from Boots pharmacy had visited and had given advice and guidance as to using the medication administration record sheets system for recording medication. The Priory DS0000039813.V301500.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The quality in this outcome area was poor. This judgement has been made using available evidence including a visit to this service. Service users are able to make choices about their daily lives, although these are limited through restrictions on their movement, inadequate furnishings and routines within the home as well as individual cognitive ability. Service users have variety, choice and wholesome food, however mealtimes do not present as a pleasurable experience. EVIDENCE: The pre inspection questionnaire received on 16th May 2006 states a full time activities co-ordinator 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. During the first site visit most service users in the lounges were being entertained or offered the opportunity to join in. The home was lively with staff attentive to service users needs. On the second site visit the evening meal of sandwiches and cake was being served and staff were busy with this task. The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 17 Care plans tracked for two service users who spent time in their rooms had no record of being offered or participating in activities since January 2006. During both site visits service users in their rooms were visited by staff for daily living requirements such as food and drink, at no time did staff spend individual time for company. A service user spoken with stated when asked if they were happy said “no” when asked what they would change they responded “someone to talk to”. Overall service users were relaxed and calm; those that were able to were wandering around the lounge. When asked about life in the home a service user said, “very nice, very nice place” they shook their head indicating no when asked if they went out in the garden and responded “would go out”. When asked if there were any trips out a service user stated, “I don’t know”. There was no evidence of service users exercising choice over where they choose to take their meals, spend their day or at what time they go to bed or get up. Visitors were seen to be coming and going and sitting with their relatives in lounge areas. There is no identified visitors room. Relatives were sitting on the patio with a relative during the second site visit. Bedrooms seen contained evidence that rooms can be personalised, service users are encouraged to bring things in to brighten up private bedrooms. It was noted that a hand written note on the wall by the sink in a bedroom had been written by a relative as a visual prompt saying “Granny don’t forget your teeth to clean, please eat today, we love you”. One visitor whose relative had been placed in a double room commented that it was “Grim” that they were “Not happy”. The pre inspection questionnaire contained a list of 2 weekly menus offering choice and variety. 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. During the second visit, which took place over tea time, there was only one person sitting in the dining room at a table and one sitting at a chair eating their evening meal. The other service users were sitting in the lounges. Due to the limited number of tables beside easy chairs, service users tried to balance their drinks and plates of sandwiches and cake on their laps. Bad practice was noted with service users being left unattended without being given support. Some service users were being given meals in their rooms, one clearly was unable to manage the process adequately. Two service users were fed sandwiches in bed. The manager stated that it was advised that one of these service users have bed rest for pressure sores. One service user was heard to ask for another sandwich, despite sandwiches being left on the trolley staff did not provide them with another sandwich or deal with her request satisfactorily. The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 18 There was a good stock of both frozen and fresh food at the home. The kitchen notice board contained an invoice for fresh meat from a local supplier. The cook stated that yesterday it was supposed to be a roast dinner but due to the hot weather they had changed this to mash and cold meat. It was noted that some large condiment bottles in the fridge were not dated on opening despite having 14 day or 4 week shelf life. The Priory DS0000039813.V301500.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The quality in this outcome area was poor. This judgement has been made using available evidence including a visit to this service. Systems are in place to enable those living and those visiting the home to raise concerns or complaints with staff. Due to the lack understanding of written risk assessments and guidelines when supporting adults who may challenge a service, service users are at risk of receiving inappropriate and inconsistent support. EVIDENCE: Relatives/visitors feedback cards were received, three of the four respondents ticked to say they did not know about the home’s complaints procedure. 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 16th May 2006 lists no complaints had been made since last inspection. No complaints had been made to the commission since the last inspection. A relative mentioned at the last inspection that ‘their only beef was the laundry”. The manager actively dealt with this. The laundry service has improved. Clothes were seen to be smart, The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 20 well cared for and neatly put away. There was one service user in their room who had trousers on that did not fit. Four service users have been admitted to A&E and there have been 3 deaths at the home since the last inspection. The manager stated that she does not keep a log of accidents as an audit trail. There are a significant number of accidents particularly pertaining to falls. Some service users had skin abrasions and bruising; it is acknowledged that they were frail and slight in build. Care plans seen did not accurately assess or 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 personal safety awareness. Accident records indicate direct aggression between some service users placing both service users and staff at risk. Risk assessments for identified risks had not been conducted. The home does not manage service users’ finances. The Priory DS0000039813.V301500.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 The quality in this outcome area was poor. This judgement has been made using available evidence including a visit to this service. Service users live in a home that is not well maintained, safe or designed to meet their needs. Service users do not have a safe area outside of the home. Service users live in a home that would benefit further 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. EVIDENCE: The pre inspection questionnaire received on 16th May 2006 lists the home to have 9 toilets; 5 bathrooms; 1 shower room; 2 single and 2 shared rooms with en suite facilities. Not all of these are suitable for use by service users. The home was very clean at the first site visit with staff cleaning throughout the inspection and any dirty areas or mess being cleaned immediately. There The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 22 was a strong smell of urine during the second visit at the entrance and food on the carpets in bedrooms and lounge areas. Overall the furniture in the lounges was old, not matching and had incontinence aids on the seats as protective covers. The private bedrooms were of the same poor standard with non- matching furniture some of which were broken i.e. with no door handles. Most of the furniture was not suitable for the service users as the doors and drawers were too heavy to open. Some rooms had ‘tatty’ curtains and one bedroom had no curtains. Room 18 has had a window put in it providing much more light to the room. Access by service users to the patio area outside the dining room was blocked by a bench that had been donated by a relative. A relative had also donated the table and chairs. The entrance from the dining room was blocked with a table and chairs. The glass in the patio door was not reinforced and the step leading to this area was uneven posing a tripping hazard. A service user and their family were sitting in this area during the second site visit enjoying tea and the view. Their enjoyment was marred by old furniture stored there. The bathroom next door to room 4 had no radiator cover, other radiators were also uncovered around the home in private and communal areas. The manager stated that the radiator was left uncovered in the toilet due to the access difficulties for service users with zimmer frames. The toilet also stands well away from the wall leaving the service user’s back unsupported. The bath surround was cracked and broken posing a hygiene threat. The flooring was uneven. The cupboard contained toiletries not named, which as discussed with the manager should be removed, as there is a risk of cross infection. In private rooms some toiletries were seen which were not named to the current occupant of the room. The basement bathroom had a bolt lock on the internal side of the door, which could not be open from the outside in an emergency; the radiator was uncovered; the bath was very high the manager stated it was not used by service users. This is the only toilet and bathroom for service users to access whose private accommodation is in the basement. The new shower room could only be locked from the inside the manager stated staff hold an emergency key. Whilst walking around the home it was noted that floor boards under carpeting outside some bedrooms, corridors, the lift and an en-suite bathroom entrance were spongy and gave way under foot. This is a serious hazard for the frail and less ambulant increasing the risk of trips and falls. A full audit by maintenance staff should be undertaken to assess and develop detailed action plan to address this. A permanent solution to this problem must be made. The visitor’s toilet has been converted into a sluice room. Racks for storage had not yet been fitted the manager stated this was as the room had only The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 23 recently been converted. A member of staff stated that visitors could now use the staff toilet on the top floor. The kitchen is not kept locked nor has a system to prevent access by service users which is relevant as some service users have rooms on the same floor. As stated earlier in the report, service users rooms in the basement are isolated and have staffing facilities in surrounding areas. Two rooms are separated by an internal door which is also a fire escape route. One side of the door was blocked by a wardrobe which the manager said was placed there deliberately to stop one service user wandering into the other’s room. One room has steps leading to it; any service user in this room needs to be fully ambulant. The staff room in the basement does not have a lock on it or hold lockable storage facilities as required by regulation 3 (a) (i) (ii). This has not been included as a requirement in this report as the owner and manager were not aware of the changes to the regulations. An e-mail with a link to these has been forwarded to them. The laundry floor has been replaced and the laundry area has been generally tidied up providing space to work. A new iron press has been purchased. Access to the laundry is from external door only, as the other access is through the kitchen, which staff stated was not used. Garden areas are not safely accessible to service users as the paved ramp has no handrails and garden paths are cracked and uneven. The garden does not provide a secure setting which is necessary for service users likely to wander. This is unfortunate as the garden could be a beautiful area with its trees and woodland. Following a previous inspection a small area to the rear of the home was fenced in, the fencing was later taken down. The manager said this had been done so that a larger secure area could be provided. The front drive is gravelled and with a metal grate in the path by the front door. Service users were seen to struggle with zimmers to cross the front drive to reach a bench on the opposite side of the drive. There is no flat path for safe access or suitable sitting places which can offer shade in hot weather to enjoy the garden. Drivers using the front access are not warned that residents might be in the vicinity. The chimney wall had a large crack down it, as did the wall at the front of the home and in a service user’s bedroom. Some of the decoration in service users’ private accommodation needs to be repaired as paint was seen to be flaking. A television on in room 18 had very poor reception. There were new commodes in each room. A bedroom was noted to have no carpet. This had been an agreement for a service user who previously occupied it and had not been reviewed when the room became vacant. The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 24 Some of the shared rooms are limited for space and not all items listed in standard 24 can fit in these rooms. As raised in the last inspection report it should be reviewed whether these rooms are fit for purpose. There was no evidence that any action has been taken to enquire if the service users who share a room choose to do so, or whether it is in their best interests. During the site visits it was very warm being some of the hottest days of the year. Fans were in use around the home and windows were open. During the second visit the manager took round ‘wet wipes’ for service users to cool themselves down. The administration office in the basement used by administration staff and the owner has a portable air conditioner and was cool. Matters still outstanding from the occupational therapist’s report conducted on the 13 August 2005, are the need for even flooring in lift areas; rails to be provided on all access steps, level and clear paths and to secure any uneven flooring/carpet in all rooms and corridors. Taps that have been renewed have not had easy push down operation or which prevent accidental continued use. Some rooms had had paper towels and soap dispensers fitted others were stated to be in hand. Recommendations still outstanding from the infection control nurse’s visit include that hand towels should be removed; wall mounted paper towels should be provided in communal areas, a keypad should be fitted to the kitchen and a separate entrance for the laundry should be provided The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The quality in this outcome area was poor. This judgement has been made using available evidence including a visit to this service. Care staff have not transferred information learnt on recent training into every day practice and record keeping in the home, to enable consistent care to be provided for service users Formal recruitment processes, checks and the lack of formal supervision do not to promote the safety and well being of service users. EVIDENCE: Comment cards from relatives / visitors were received, 2 out of the 4 responses had ticked to say not enough staff on duty. The pre inspection questionnaire received on 16th May 2006 lists 3 service users with high needs, 11 service users with medium needs and 16 service users with low needs. The Department of Health Residential Forum calculations total 514 care hours with a total of 601.94 care hours and 765.74 total duty hours with 19.14 working full time staff required. According to the pre inspection questionnaire the home’s staffing consists of 557 care hours provided per week; 17 care staff and 8 ancillary staff employed. Eight staff have left, 1 retired, 3 for personal reasons, 1 career change and 3 to return to country of origin. Nine staff are qualified to NVQ level 2 or above totalling 53 of care staff, 7 staff hold a current first aid certificate. Staff training identified in the pre The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 26 inspection questionnaire lists previous and future training as: - all staff to do fire training September 06; manual handling October 06; POVA March 06; fire training April 06, understanding dementia level II x 10 staff; safe handling of medicines 7 staff; communication and record keeping all staff, care planning 4 staff, healthy eating and nutrition 12 staff booked May/June; infection control 12 staff June 06, basic food hygiene all staff July 06. Copies of staff certificates were seen in staff files. The manager was in the process of devising a staff training matrix. Training for staff has increased and good practice was noted as staff who were not providing personal care had been put on a dementia care course. As the manager explained, this would help them to better understand the needs of service users with dementia. The staff rota was not complete or accurate as to staffing hours or staff on duty. The home employs extra staff for laundry, domestic, cook and kitchen assistant and an activity coordinator Monday to Friday. A team leader covers each shift, the manager works some days as supernumerary. The rota indicated that although a flexi shift had been identified to cover busy periods. These hours were being used on a regular basis to cover vacant shifts, so extra staff were largely not provided. During the site visit on Thursday 20th there were ample of staff on duty with extra staff for care and activities arriving during the inspection. There was no on call rota identifying whom to call in the event of an emergency. The manager explained that staff generally telephoned her and the team leaders covered on call as well. The staff files viewed 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 undertake care. Formal supervision to offer care staff regular 1:1 time with their line manager at least 6 times a year still has not been fully implemented. One staff file had one reference although the manager chased the second reference up with a telephone call during the site visit. Another member of staff had no references or other paperwork. The Priory DS0000039813.V301500.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37, 38 The quality in this outcome area was poor. This judgement has been made using available evidence including a visit to this service. The management and administration of the service is failing to provide service users with a safe quality service. EVIDENCE: The manager has successfully completed the process of becoming registered manager with the CSCI. There is a deputy manager and external support by the clinical director of care. The pre inspection questionnaire received on 16th May 2006 records maintenance schedules and associated servicing. It lists that the fire officers last visit was on 01/12/06; fire equipment manufacturers last check on 21/4/06; fire extinguishers serviced on 3/11/05, fire lecture training on the 20/4/06; health and safety and Environmental Health Officer visit in July 2005; central heating service on 03/10/05; approved electrical contractor visit The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 28 on 21/09/05 although the electrical wiring certificate issued has no date; hoists/adaptations serviced on 22/3/06 with a new firm being used contracted on an annual basis; the emergency call system serviced on 21/4/06 and C.O.S.H assessments on the 12/3/06. The pre inspection questionnaire received on 16th May 2006 lists policies and procedures implemented and dates of review, omitted are annual development plan for quality assurance; death of a service user; emergency and crises; risk assessment and management. The policies had been ticked to say most had been reviewed on 10/08/05. All policies can be printed off in large print for service users. Staff undertakes accident recording. Records seen evidenced a high proportion of accidents which were falls related. Care plans, reviews and risk assessments did not reflect this. Records seen are not monitored or audited to identify patterns, trends or the need to review the risk assessment or individual care plans. The pre inspection questionnaire received on 16th May 2006 states the home does not act as appointee for service users; 2 service users are subject to guardianship. A service users personal hairdryer was noted not to have been portable appliance tested. Disposable razors were noted to be in service users’ rooms with no risk assessments in place or being locked away for safety. Cereals were kept in the dining area in a container that had not been dated. Some pickles and sauces in the fridge and a frozen homemade brownie cake were not dated. Deficits in the maintenance of the building include: • • • The lino in the food storage area is ripped and uneven posing a hygiene risk. An assisted bath is cracked and in need of replacing. The flooring in some areas around the home is uneven and spongy underfoot. This is an ongoing problem for the home due to the age of the building and action has been taken to straighten the carpet but not to have levelled the floorboards. The doors leading to the passageways and stairs that open inward pose a potential danger, as they do not have glass to enable a clear view if anyone is on the other side of the door. This should be discussed with the fire officer where they are fire doors. A review should be made as to the security of the The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 29 laundry room entrance door that has glass in it. There was no evidence that this has been considered or addressed. All combustible items must be stored appropriately especially in storage cupboards where electrical equipment is located. This has been raised in past inspections but not addressed. The administration office in the basement had a wooden filing cupboard that could not be locked that contained details of service users. 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. Not all staff have received supervision. Service users care plans are computerised. There is no evidence that service users or representatives are included in assisting to maintain these. The administration office in the basement and staff room have been broken into. The security of the basement needs to be considered fully with risk assessments for the service users who reside there who may not be able to use the call bells for assistance in the event of an emergency. The Priory DS0000039813.V301500.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 1 1 1 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 1 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 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 2 1 The Priory DS0000039813.V301500.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 4(1)(c) Requirement The registered person shall compile in relation to the care home a written statement of purpose, which shall consist of a statement as to the matters listed in Schedule 1. Identified in the text. 5(2) The registered person shall supply a copy of the service users guide to each service user. 5(1)(b) Each service user is provided with a statement of terms of conditions at the point of moving into the care home. 14(1)(c)(d The registered person shall not )17(1)(a) provide accommodation to a service user at the care home unless there has been appropriate consultation regarding the assessment with the service user or representative of the service user. That schedule 3 (1)(a) the registered person carries out a needs assessment covering all areas identified in standard 3.3 14(1)(d) The registered person shall not provide accommodation to a service user at the care home DS0000039813.V301500.R01.S.doc Timescale for action 27/08/06 2 3 OP1 OP2 27/08/06 03/08/06 4 OP3 03/08/06 5 OP4 03/08/06 The Priory Version 5.2 Page 32 6 OP7 15(1) 7 OP7 13(4)(c) 8 OP7 15(2)(b) (c) 9 OP8 12(1)13 (1)(b) 10 The Priory OP8 17(1)(a) unless the registered person has confirmed in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service users needs in respect of his health and welfare. Unless it is impracticable to carry out such consultation, the registered person shall after consultation with the service user, or a representative of his prepare a written plan as to how the service users needs in respect of his health and welfare are to be met. This is carried over from the last inspection. The registered person shall ensure that unnecessary risks to health and safety of service users are identified and so far as possible eliminated. This is carried over from the last inspection. The registered person shall keep the service users plan under review; where appropriate and unless it is impracticable to carry out such consultation, after consultation with the service user or a representative of his, revise the service users plan. This is carried over from the last inspection. The registered person shall ensure that the home is conducted so as to promote and make proper provision for the health and welfare of service users; to make proper provision for the care and where appropriate, treatment and supervision of service users. This is carried over from the last inspection. Records to be kept: details of DS0000039813.V301500.R01.S.doc 27/08/06 27/08/06 27/08/06 27/08/06 27/08/06 Page 33 Version 5.2 11 OP9 13(2) 12 OP10 12(4)(a) 13 OP12 12(3) 14 OP13 23(2)(i) 15 OP14 12(2) any plan relating to the service user in respect of medication, nursing, specialist health care or nutrition. Schedule 3 (o) (m) This is carried over from the last inspection (m) is added to this inspection. The registered person shall make arrangements for the recording, handling, safe keeping, safe administration and disposal of medication received into the care home. In that the actions are followed as per the pharmacist letter following their inspection. This is carried over from the last inspection. Added to this inspection are items as identified in the text. The registered person shall ensure the care home is conducted in a manner, which respects the privacy and dignity of service users. 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. The registered person shall having regard to the number and needs of the service users ensure that suitable facilities are provided for service users to meet visitors in private accommodation which is separate from the service users own private rooms. The registered person shall so far as it is practicable enable service users to make decisions with respect to the care they receive and their health and welfare. DS0000039813.V301500.R01.S.doc 27/08/06 27/08/06 27/08/06 27/08/06 27/08/06 The Priory Version 5.2 Page 34 16 OP18 17 OP19 18 OP20 19 OP21 This is carried over from the last inspection. 13(4)(c) The registered person shall ensure that the care home is conducted unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. 23(2)(a,b, The registered person shall c,d,) having regard to the number and needs of the service users ensure that the physical design and layout of the premises to be 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. Full action plan required. 23(d)(f)(i) The registered person shall having regard to the number and needs of the service users ensure that all parts of the home are kept reasonably decorated; the size and layout of the rooms occupied by service users are suitable for their needs; suitable facilities are provided for service users to meet visitors in communal accommodation, and private accommodation which is separate from the service users own private rooms. Full action plan required. 23(2)(j) 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. DS0000039813.V301500.R01.S.doc 27/08/06 27/08/06 27/08/06 27/08/06 The Priory Version 5.2 Page 35 20 OP22 16(2)(c) 23(2)(n) 21 OP25 13(4)(a) (c) 22 OP27 17(2) 23 OP27 18(1)(a) This is carried over from the last inspection. 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 service users and ensure that suitable adaptations equipment and facilities are provided. In that recommendations of the occupational therapy assessment on 13/08/04 be implemented. This is carried over from the last inspection. 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 the radiators must be guarded or operated at low surface temperatures. The action plan following the last inspection stated that covers had been ordered for the two remaining radiators. The home shall keep and maintain a copy of the duty roster of persons working at the care home, and a record of whether the roster was actually worked. Schedule 4 7 This remains not met from the last inspection and the inspections conducted on 29/9/04 and 27/7/04 The registered person shall having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure that at all times suitably competent and experienced persons are working at the care home in such numbers as are DS0000039813.V301500.R01.S.doc 27/08/06 27/08/06 27/08/06 27/08/06 The Priory Version 5.2 Page 36 24 OP29 19 25 OP30 18(1)(c) (i)4(c) 26 OP37 17(1)(a)( b)(2)(3) 27 OP38 12(1)4(a) 13(3) appropriate for the health and welfare of service users. This is carried over from the last inspection. The registered person shall not employ a person to work at the care home unless he has obtained in respect of that person the information and documents specified in paragraph 8 of schedule 2. That he is satisfied on reasonable grounds as to the authenticity of the references referred to in paragraph 5 of schedule 2 Regulation 2 (8) 19 1 (c) in respect of that person. This is carried over from the last inspection. The registered person shall, ensure that persons employed by the registered person to work at the care home receive training appropriate to the work they perform. In that induction training is completed for all staff. The registered person shall ensure that records referred to in paragraphs (1) and (2) are kept up to date. That the Data Protection Act is followed in respect of the records of service users not kept secure. Regulation 15 (1) (2) This is carried over from the last inspection. Old service users files in the staff room have been made secure. The registered person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users; in that the items identified in the text are addressed. 27/08/06 27/08/06 27/08/06 27/08/06 The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 37 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 OP2 Good Practice Recommendations That the policy and procedures for shared rooms, includes shared rooms to be shared by either service users who both have a diagnosis of dementia or both fall into the category of old age. This has been carried over from the last inspection. It continues to be strongly recommended that the service user contract specify the category of service user as being either old age or dementia. This has been carried over from the last two inspections and identified in the inspection conducted on 29/09/04. It is yet again very strongly recommended that a review be made of the meal times routine in that service users are supported to eat meals in the dining area and not in the lounges. This has been identified in the last inspection. The action plan stated the evening meal is taken in the dining room. It is again very strongly recommended that service users who currently share a room have the opportunity not to share. That the policy and procedures for admitting service users to shared rooms apply to those already sharing. This is carried over from the last inspection. It is recommended that, where practicable, service users bedrooms be furnished as identified in standard 24. That a review be made of the space available with shared rooms. There was again no evidence that this had been considered or service users assessed or consulted as to their choices, preferences or needs and of this being recorded. This is carried over from the last inspection. It is strongly recommended that the recommendations from the infection control nurse be fully implemented. It is very strongly recommended that the manager and the deputy have more time working as supernumerary for office and management tasks. 2 OP2 3 OP15 4 OP23 5 OP24 6 7 OP26 OP27 The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 38 8 OP29 It is very strongly recommended that the records of all staff working at the home be kept at the home i.e. temporary managers, additional workers from other homes. It is very strongly recommended that the action plan and agreed timescales to implement the requirements made at the inspections be progressed within a reasonable timescale. This is carried over from the last inspection. It is strongly recommended that the omitted policies and procedures identified in the text be developed. It is strongly recommended that service users and if appropriate representatives have the opportunity to help maintain their personal records. 9 OP33 10 11 OP33 OP37 The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 39 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Priory DS0000039813.V301500.R01.S.doc Version 5.2 Page 40 - 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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