Inspection on 31/07/07 for The Priory

This inspection was carried out on 31st July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 02/03/07

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 Joy Hoelzel Unannounced Inspection 31st July 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.V341753.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.V341753.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 Ms Kay Davies Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places The Priory DS0000064067.V341753.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Priory Nursing and Residential Home may provide care for a maximum of 37 older people, of whom up to 25 may require low to medium dependency nursing care. Staff involved in the care of Residents must be suitably qualified, competent and experienced persons who are deployed in such number/skill-mix so as to be minimally in accordance with the Staffing Notice issued by Shropshire Health Authority. 08:00-14:00 22:00-08:00 1 Qualified Nurse Qualified Nurse (RGN or EN) or EN) 6 Care Staff Care Staff 14:00-22:00 1 Qualified Nurse (RGN or EN) 4 Care Staff 1 (RGN 3 3. NB - Additional staff must be on duty when high dependency service users are accommodated - These minimum levels are for direct nursing and personal care only, i.e. - they do not include ancillary staff. The above numbers may include the Manager when he/she is engaged in direct care provision, but are exclusive of the Manager when he/she is carrying out managerial duties. 2nd March 2007 Date of last inspection Brief Description of the Service: The Priory is a privately owned Care Home registered to provide accommodation, personal and nursing care for a maximum of thirty seven older people. Situated on the eastern edge of the Shropshire town of Wellington, with local amenities available a short walk away the home is set in its own grounds, with a car park to the front. The building comprises a large converted town house with a purpose built extension added in recent years. Single and twin bedrooms are available, some benefit from an en suite facility. The home has a selection of sitting and dining areas The Priory DS0000064067.V341753.R01.S.doc Version 5.2 Page 5 Weekly fees for the service range from £ 348.61 - £ 585.99. Information of the home and the provision of the service are available in the statement of purpose and service user guide, both documents have recently been revised and are readily available. Commission for Social Care Inspection Reports for this service are available from the provider or can be obtained from www.csci.org.uk The Priory DS0000064067.V341753.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours on Tuesday 31st July 2007. It was conducted by one Commission for Social Care Inspection regulation inspector. Twenty four of the thirty eight National Minimum Standards for Care Homes for Older People were inspected as they are viewed as key standards for services. Thirty five people are currently living at the home and during the inspection were observed to be accessing all areas of the home. The registered manager was on the premises supported by one registered nurse, six care staff, and ancillary personnel. Three case files were selected for case tracking, relevant documents were inspected, discussions were held with people living at the home, visitors, members of staff and the manager. Observation was made of the various daily activities and a tour of the premises was conducted. An Annual Quality Assurance Assessment (AQAA) had been completed by the manager and submitted to CSCI prior to this inspection, offering a full overview of the home. On site surveys were distributed during the inspection and completed by people living, working and visiting the home. The comments received are included in this report. What the service does well: The home provides people with a comfortable place in which to live. The manager demonstrated a good in-depth knowledge of the resident group and the conditions and dilemmas associated with the ageing process. Throughout the service there is a highly evolved understanding of the equalities and diversity needs of the individuals who use the service. Staffing numbers are maintained to ensure that people receive the care they need. Comments received throughout the inspection and included in the on site survey – ‘Look after me well, the care given is very good’ The Priory DS0000064067.V341753.R01.S.doc Version 5.2 Page 7 ‘ Good food and all round attention’ ‘ I am very happy and have no complaints’. ‘My relative is clean and well cared for, the staff are ok and the food is excellent’. 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 The Priory DS0000064067.V341753.R01.S.doc Version 5.2 Page 8 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Priory DS0000064067.V341753.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 DS0000064067.V341753.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP 3,6 Quality in this outcome area is good. People are not offered a place at the home until a full needs assessment has been undertaken this ensures that the care needs of the individual can be fully met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three case files were selected for inspection and included the file of a person who had recently moved into the home. Information of a persons care needs are obtained prior to offering a placement at the home. The Priory DS0000064067.V341753.R01.S.doc Version 5.2 Page 11 One visitor explained that they visited the home to have a look around before the decision was made for their relative to move in. The person was unable to visit due to health reasons. The service user guide includes information on admission to the home and states that people are encouraged to visit the home and to meet the staff and other people in residence. The home does not offer an intermediate care service. The Priory DS0000064067.V341753.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. JUDGEMENT – we looked at outcomes for the following standard(s): OP 7,8,9,10 Quality in this outcome area is good. Each person has a plan of care it is written in plain language, is easy to understand and looks at all areas of the individual’s life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All people living at the home have a plan of care that is initially based on the information gained prior to moving into the home it is then reviewed at regular intervals. A recent audit of all care plans (July) by the manager identified some omissions in the recording of information, staff have been instructed to review the plans to ensure that full information of a persons care needs are documented. The Priory DS0000064067.V341753.R01.S.doc Version 5.2 Page 13 Three case files were selected for inspection and all included an assessment of the activities of daily living. The care plan was then based on the assessed need, the aim and the care to be provided. The care plans cover areas of healthcare including mobility, pressure area care, maintaining a safe environment, continence and nutrition. The documentation relating to pressure area care is comprehensive and details the advice and support from the healthcare specialists, the type of dressings to be used, the frequency of the dressing change and any improvement/deterioration of the wound area. Body maps and individual recording sheets are used to record the interventions and monitor the progress of the treatments. The care plans of two people who have cognitive difficulties were looked at. Evidence points to the specialised care needs of these people are being satisfactorily met. Whilst it was not possible to engage them fully in conversation both were well dressed, clean, tidy and appeared quite happy in their surroundings. One visitor commented ‘My relative is clean and well cared for’. Inspection of medicine storage and administration records, demonstrated the home’s practices meet the guidelines of the Royal Pharmaceutical Society. The Primary Care Trust Community Pharmacist visited the home in May 2007. During the tour of the premises external preparations were in some bedrooms the containers did not have a date of opening, staff were advised introduce the practice and discard tubs after one month of opening and tubes after 3 months of opening. Staff were observed to be offering many choices to people throughout the day and carrying out the interventions in a calm, efficient and competent manner. People looked well groomed, care for and nourished. The Priory DS0000064067.V341753.R01.S.doc Version 5.2 Page 14 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): OP 12,13,14,15. Quality in this outcome area is good. People who live at the home are involved in meaningful daytime activities of their own choice and according to their individual interests and capabilities. The meals are balanced and nutritional and cater for the dietary needs of the individuals using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One member of the care staff team is now responsible for arranging the social and leisure programme (9 hours a week) with input from the other carers. A social activity committee meet to arrange and facilitate activities. In house and community based activities that are organised and can be either a group activity or on a one to one basis. The Priory DS0000064067.V341753.R01.S.doc Version 5.2 Page 15 During the morning of the inspection some people were watching TV, listening to music whilst others were reading the newspapers, or just sitting watching the happenings of the day. Comments received in the surveys completed by people living, working and visiting the home were that improvements had been made to the type and frequency of the activities. Some people indicated that more activities especially ‘sing-a-longs’ would be ‘lovely’. Visitors are welcome to visit the home at times to suit their friend or relative. During the tour of the premises many bedrooms contained possessions of personal, religious and cultural significance. People have the choice of where to take their meals but are encouraged to go to the dining areas whenever possible. The dining rooms are well fitted and prepared in advance of the meals. People living, visiting and working at the home commented in the in the surveys ‘Food is varied and nutritious’, ‘Good staff and food’. One person thought that the food and meals could be improved but did not indicate in what way. Staff were observed to be encouraging and assisting people with the midday meal in a discreet way showing patience and understanding of the individuals needs. The Priory DS0000064067.V341753.R01.S.doc Version 5.2 Page 16 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): OP 16,18 Quality in this outcome area is good. The service has a complaints procedure that is clearly written, easy to understand and included in the service user guide. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager confirmed that no complaints had been made since the last inspection. A detailed complaint procedure is included in the service user guide, each person has been supplied with a copy. The policies and procedures for complaints and safeguarding adults are currently under review. A training matrix has been developed and indicates most staff have had training in protection of vulnerable adults. The home offers a facility for residents to deposit personal monies for safekeeping; records relating to this are maintained and fully receipted. Currently the money is pooled and kept in the safe. The Priory DS0000064067.V341753.R01.S.doc Version 5.2 Page 17 It was recommended that each person’s money is kept separately and that another person carries out a monthly audit. The Priory DS0000064067.V341753.R01.S.doc Version 5.2 Page 18 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): OP 19,21,24,26 Quality in this outcome area is adequate. The home provides a physical environment that generally meets the specific needs of the people who live there. The home is comfortable, with plans to improve the decoration, fixtures and fittings. There continues to be a potential risk of cross infection due to property works and repairs to equipment not being carried out in a timely way. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Redecoration and refurbishment continues in the private and communal areas. The Priory DS0000064067.V341753.R01.S.doc Version 5.2 Page 19 The manager explained the current plans for an extension to the laundry area. Plans have now been drawn up and the work is to begin shortly. Work is still outstanding for the alterations to the bathroom and shower rooms again the manager confirms that the work will begin shortly. The dining area is planned for refurbishment. The surveys completed by people living at the home in the ‘what the home could do better’ section included comments ‘Curtains are horrible… Better garden… Wallpaper…’ Staff indicated that – ‘Old part of the home could be improved’, ‘More could be done on the décor and improvement of bedrooms’. One person was not at all satisfied with the accommodation, observation of the room evidenced that the room was without a wash hand basin, the toilet for their use is across the corridor. An explanation was offered by the manager regarding this person’s accommodation. The service user guide states The Top Unit – there are nineteen single rooms; all have wash hand basins with toilet facilities. The Bottom Unit – there are eighteen single rooms and two double rooms all have wash hand basins with toilet facilities’. There are a variety of sitting and lounge areas around the home ensuring that people are able to choose where to sit during the day. The gardens are well maintained, and accessible, the main drive has some potholes in and would benefit from repair. During the tour of the premises the bedrails appear to be fitted correctly it is recommended that at a full audit be undertaken to ensure that the bedrail and beds are compatible. All hot water outlets barring one have been fitted with a safety valve to reduce the risk of a scalding incident. The Priory DS0000064067.V341753.R01.S.doc Version 5.2 Page 20 Hand wash facilities have been provided in all communal areas and at the point of the delivery of care. The home has two automatic sluice disinfectors for the use of the safe disposal of bodily waste; neither are in working order with staff commenting that they haven’t worked ‘for ages’. The Priory DS0000064067.V341753.R01.S.doc Version 5.2 Page 21 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): OP 27,28,29,30 Quality in this outcome area is good. There appear to be enough staff available to meet the needs of the people using the service, with the staffing structure based around delivering outcomes for the people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: General observations and discussion with staff confirmed that staffing numbers and skill mix enable a service provision, which meets the care needs of the people living at the home. Staff were observed to carry out their duties in an enthusiastic and professional manner. All service users looked well groomed and it was obvious that the staff assisted people with maintaining high standards of personal care. Comments in the on site survey by a visitor indicated that the ‘The home does well with the efficiency of the carers’ The Priory DS0000064067.V341753.R01.S.doc Version 5.2 Page 22 The manager is currently carrying out a full audit on the staff personnel files and is ensuring that the required safety and identity checks are up to date. A training matrix has been developed indicating the training and development needs of staff. National Vocational Qualification training is ongoing. Staff indicated inn the surveys that improvements in the last six months have been made in – ‘Training, good skills and communication between manager, staff, team working together morale has improved’. The Priory DS0000064067.V341753.R01.S.doc Version 5.2 Page 23 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): OP 31,33,35,38 Quality in this outcome area is good. The Manager has the required qualifications and experience and is competent to run the home. She has a clear understanding of the key principles and focus of the service, based on organisational values and priorities and is leading and influencing the development of a strong staff team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Kay Davies has been in the manager’s position since January 2007 and successfully completed the formal process in May 2007. The Priory DS0000064067.V341753.R01.S.doc Version 5.2 Page 24 Ms Davies is a Registered General Nurse and has been manager at other care homes She demonstrated a good knowledge of her managerial responsibilities and of the people living at the home. People living and working at the home offered positive comments of the style of leadership and stated that the manager was ‘ very supportive, and approachable, and would have no hesitation but to ask to see her if there were any concerns’. Many people indicated in the on site surveys that the management of the home had greatly improved over the past six months. Staff meetings are arranged on a regular basis with separate meetings for the senior staff. Quality assurance and monitoring of the home is being developed with a complete review of all documentation, satisfaction questionnaires have been distributed to people living and visiting the home. The results have yet to be audited and the findings actioned. The home offers a facility for residents to deposit personal monies for safekeeping; records relating to this are maintained and fully receipted. Currently the money is pooled and kept in the safe. Recommended that each person’s money is kept separately and that another person carries out a monthly audit. Weekly, monthly and annual testing of the equipment and premises are conducted with records kept. An external contractor last reviewed the fire risk assessment in April 2007, the manager confirmed that work is continuing to ensure compliance with the recommendations of the report. The Priory DS0000064067.V341753.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 X 2 X X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 The Priory DS0000064067.V341753.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 OP24 Regulation 23(2)(j) Requirement All bedrooms must be provided with a wash hand basin (unless en suite with wash hand basin are provided). Timescale for action 31/12/07 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 a plan be developed for the redecoration/refurbishment of the premises, together with a programme, which includes dates for commencement and completion of remaining work. It is recommended that routine checks be carried out on the bedrails, with records kept, to ensure that they are fitted correctly, safe and compatible with the beds. It is recommended that the main drive be repaired. It is recommended that the alteration, repairs and refurbishments of the bathroom and shower room be completed without delay. It is recommended that the extension to the laundry be completed without delay. DS0000064067.V341753.R01.S.doc Version 5.2 Page 27 2 3 4 5 OP19 OP19 OP21 OP26 The Priory 6 7 OP26 OP35 It is recommend that for the safe disposal of bodily waste the sluice disinfectors are repaired and/or replaced. It is recommended that all residents’ personal monies kept at the home for safekeeping is handled separately and not pooled together. The Priory DS0000064067.V341753.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Shrewsbury Local Office Commission for Social Care Inspection 1st Floor, Chapter House 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.V341753.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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