Inspection on 05/07/05 for The Priory

This inspection was carried out on 5th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Priory 11/07/07

The Priory 18/01/07

The Priory 20/07/06

The Priory 06/03/06

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 5LH Lead Inspector Maria Tucker Announced 5 July 2005 9:30 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 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. H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 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 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 Mrs Grace Elizabeth Harrison CRH Care Home 32 Category(ies) of DE(E) Dementia - over 65 (14) registration, with number OP Old Age (18) of places H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The residents within the categories of older people and older people with a mental infirmity will be over 65 years of age on admittance. Two residents with learning disabilities their dates of birth are 03.091931 and 09.09.1936. Date of last inspection 29/9/04 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 on all of the levels, the basement contains the kitchen, managers and administration office, the handy persons room and storage. H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, the first in the year running from April 1st 2005 to March 31st 2006. The inspection lasted from 9.19am until 6.19pm. The inspection was conducted by Maria Tucker, supported in part by Paul Coop Regulation Manager and Jane Vaughn Pharmacy inspector. The pharmacy inspector has forwarded the home an additional visit letter containing her findings and subsequent Requirements and Recommendations. This letter will be made available on request to members of the public or other enquirers. Time was spent meeting the manager, responsible individual and director of care going through various records and documentation. About two hours was spent meeting service users. Three relatives were spoken with. Four staff on duty were spoken with. A tour of the premises was undertaken. Due to the nature of some of the service, it is difficult to reliably incorporate accurate reflections of the service users in the report. Some judgements about quality of life and choices were taken from direct conversation with service users and observation followed by discussions with staff, relatives and evidencing records held in the home. 13 Comment cards were received from service users. A comment filled out by a service user when asked do the staff treat you well? Responded, “No complaints received from staff”. 9 comment cards were received from relatives comments included “I live a great distance away, but am kept extremely well informed” and “while visiting I have been aware there have been occasions when staff shortages are apparent”. 1 comment card was received by a health professional stating, “any suggestions or requests are acted upon promptly, the atmosphere is always good, I have never heard a raised voice”. The pre-inspection questionnaire and the provider’s self-audit forms were received. This home was overall found to be a failing service providing a poor quality of life for those service users who reside there. The home has declined rapidly since the last inspection, which both the internal and external management have failed to recognise. What the service does well: H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 6 The relationship between staff and the relatives is positive with comments such as “very lovely staff” and “staff are brilliant”. Some staff spoken with were familiar with the service users individual behaviours and preferences. In particular service users who had been at the home for some considerable time. During the inspection staff were seen to be kind and compassionate towards the service users. Some staff expressed their feelings of sadness at the poor standard, and level, of service the service users were receiving. Comments received included “They don’t get attention, they all need attention” and “I would like my … to get old in a dignified way”. The menu offers choice and variety for breakfast and lunch. An alternative is available at tea time on Monday, Wednesday and Friday. What has improved since the last inspection? What they could do better: The pre-admission assessments to be expanded upon and specific needs associated with dementia understood and met. The care planning system; reviews; and risk assessments must be completed, monitored and amended as appropriate. They should be made available for service users and those who need it. The service users health and well being needs to be recorded, monitored, met and appropriate action taken to promote this area. H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 7 Service users choice, preferences, dignity and rights must be respected and promoted. Service users and if appropriate their representatives must be consulted about the running of the home and proposed changes before they occur. Entertainment, leisure and recreation opportunities provided. Create a stimulating environment with equipment, activities and daily routines suitable for the service users needs and understanding. The furniture and furnishings in the home that are not in good condition, or unable to be cleaned thoroughly, need to be replaced. The procedures for infection control need improving, all staff then need to follow. The staffing levels should reflect the needs of the service users and the routines of the home. The staff training needs to cover all mandatory and specific topics related to the service user group. The medication policy, procedures and practices must be improved upon as per requirements and recommendations made in separate additional visit letter from the pharmacy inspector. Current medication management practices in the home do not ensure that service users receive an acceptable level of care. 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. H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 8 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 Standards Statutory Requirements Identified During the Inspection H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 9 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 standard(s) 1, 2, 3, 4. Service users are at risk as they do not receive full information on which to base their decision to move into the home. Limited assessments are conducted and service users with dementia cannot expect to have their specific needs met. EVIDENCE: A revised version of the homes Statement of Purpose and service users guide was given to the inspector. They did not contain the items identified, and required, during the last inspection. None of the service users had a contract provided. Families spoken with were unaware of these. The assessment format conducted by the home prior to service users moving in were not comprehensive, particularly for service users with a diagnosis of dementia. The individual life style and choices information contained in the assessments did not form part of the care plan. During the inspection a fax of a care managers assessment came through for an emergency admission of a service users arriving at 8pm. The manager had agreed to admit them based on receipt of this assessment. H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 10 There was no evidence of needs being met for service users who have dementia. A staff spoken with was unfamiliar with what dementia was stating, “….has short term memory, is that dementia?”. During the inspection 2 service users were sitting crying and in distress for most of the time; 3 others were seen to constantly move towards the front door and attempting to open it. Staff were seen to redirect them back into the lounge and sit them down and give some reassurance to those in distress i.e. to comfort them by putting their arm around them and saying “don’t cry you will make me cry”. H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 11 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 standard(s) 7, 8, 9, 10, Service users receive basic care with little or no dignity being afforded. EVIDENCE: The care planning was very limited in the information recorded. Details on how preferences and choices were to be met or specific behaviours supported and managed were minimal. Access to the computerised care plans is via 1 terminal in the lounge that only 3 staff have access to. Up dated care plans were not available for staff. There were no risk assessments or strategies to support specific risks or behaviours. Following a recent incident there had been no risk assessment conducted to minimise the risk or the care plan reviewed. A relative spoken with had never been invited to a review or had the care of their relative discussed. There was no evidence of formal reviews taking place or of service user involvement. A service user had got a dressing on their hand, following an incident where the manager had stated they had got it caught in between 2 Zimmer frames. The accident form could not be found; the manager stated the district nurse had applied the dressing and that the nurse had taken the notes. The dressing had come loose and the service user was picking at the open wound. There was no action taken to either clean and redress the wound or contact the H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 12 district nurse. Relatives spoken with confirmed that the optician comes into the home. Some of the care plans did state “to encourage independence”. There was no regular physical activity on offer or any exercise indicated in the care notes. Two service users were seen to have remained in their seats throughout the whole inspection, including meal times. There was little evidence that the service users psychological health is monitored regularly, or preventative and restorative care provided. A service user spoken with who was unkempt, withdrawn and sad told the inspector “I am not happy at all here”. The manager described that this was due to their family going on holiday without them; that they had been referred to a psychiatric nurse as they were depressed. The care plans recorded service users weights and stated encourage food or fluid. There was no monitoring in place or had periodic nutritional screening taken place. Some service users had lost weight and although the staff were aware of this no action had been taken to address this. A care plan recorded that a service user was to spend 1 to 1 time with their key worker and have a weekly holy communion, neither of these were occurring. Service users were escorted back into the lounge areas; only 1 was in their room. From records seen in the notes and discussions held with staff some of the service users wander into other service users rooms; on one occasion a service user had used another service users commode; at other times a service users was found in another service users bed. None of the service users rooms were locked. Relatives were seen to be sitting on footstalls while visiting. Staff spoke of how they did not have the time to do anything other than what had to be done. H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 13 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 standard(s) 12, 13, 14, 15, Service users have a very poor standard of daily living. Individual needs or choices are not promoted. EVIDENCE: The routines of the day offer little dignity or stimulation. There were no activities on offer; no service user was taken out or went into the garden; unless the service users were able to move around unaided they remained in their chair; service users were escorted into the dinning area for lunch some waiting 50 minutes before being served; tea is served in the lounges, on service users laps, with the mugs of tea on the plates with thier sandwiches and cake. 1 service user had a colouring book and another had a puzzle. Many spent the day asleep. The television was left on in the lounge, it was not monitored as to the programmes and no remote control was available. The inspector sat with a service user while they were watching the television, a programme was on showing a woman in underwear the service user commented about the television programme that “all sorts of silly things they have been doing, who wants to look at black bra and pants on television”. A service user when asked what they had planned for the day said “I’m doing nothing today”. One service user happily told the inspector that they go to a luncheon club on a Monday. A relative spoken with said their “…was extremely happy” and “I am quite happy with everything”. Two relatives commented “entertainment would be nice” and there was a “lack of entertainment”. H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 14 There were 2 new service users and 1 emergency admission planned that evening all of who had dementia. There was nothing in place to support them with the move into a new environment nor did the home have any structures or systems to teach people with dementia where they’re room, the toilets and other important areas were. The only choice service users were seen to be given was what they preferred from the options available at lunchtime. A service user spoken with about the choice of food said “on the board dinner, I can’t read it, I don’t ask, I just leave what I don’t like, every night sandwiches”. Sandwiches were on the menu for tea every night except on 3 nights a week when an alternative, i.e. sausage roll was available. Service users and where appropriate representatives are not informed or consulted about the changes in the home or the service they are provided with, for example the taking away of a storage facility to provide accommodation for 2 workers to share a room and the agreement that they can live there and share the bathroom and toilet provided for service users. H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 15 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 standard(s) 16, 18 Service users cannot feel safe or secure in their environment or with the service that they receive. EVIDENCE: The home has no complaints recorded. A comment received by a relative stated “my …needs to wear support tights at all times owing to ankle swelling we have had to complain several times it has not been done”. Feedback gained from relatives was that they were overall happy and had no complaints, 1 commented that they “feel able to raise concerns”. The service users who have dementia did not have any of their needs associated with this condition either recognised or met. The effects of service users behaviours on others was not acted upon or considered, for example one service user was wandering around patting other service users on the head; two service users were trying to get out of the front door at the same time, one service user squashed the other ones fingers in the process; one service user has gone missing from the home on 2 occasions. The piano had been placed at the window to stop the service user from climbing onto the chairs and out of the window. There was no guidance on the management of behaviours for staff. The majority of staff had not received adult protection training or any training for dementia or behaviour management. The level of need of the service users in the home has increased considerably. It was explained that service users who had been there for a period of time have naturally declined with age but they did not have a diagnosis of dementia. The inspector, nor the staff were able to differentiate which service users were elderly frail from those who had dementia. The level of care received by service users is very basic and does not cater for any specific needs related to age or frailty. H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 16 The commission has been made aware of 2 staff raising concerns about the level of care. Comments made by staff during the inspection included “we do try most of us put in 100 but when pushed there is always something that gets overlooked”, “they don’t get the attention they need”. There have been 12 admissions to accident and emergency and 4 deaths, 3 at the home since the last inspection. H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 17 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 standard(s) 19, 21, 22, 23, 24, 25,26. Service users live in poor conditions that offer little dignity or respect. EVIDENCE: The environment offers very little dignity for service users especially those in shared rooms who have commodes; in all of the rooms incontinence aids were on view; many had items stored on top of the wardrobes; the furniture and equipment in individual rooms were mainly of a poor standard i.e. not matching, old and in a poor condition, stained bed bases and soft furnishings that could not be properly cleaned. The size and layout of the rooms are not ideal, efforts have been made to arrange the rooms so that as far as it is possible individual space is provided. Some of the service users private bathrooms and toilets were used as storage i.e. wardrobes in as there was not enough space in the double room. Bedroom 18 has no ventilation or accessible view, as it is a fire exit door, it was also noted to be cluttered and not providing a clear exit. The laundry floor remains permeable One service user spoke about their room saying “I’v got a television up there”. H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 18 The home has 4 bathrooms, currently one bathroom is being converted into a shower room; 1 bathroom is unsuitable for use, so service users in the basement have not got access to bathing facilities on that level; one bathroom has a very long bath and is difficult for service users to negotiate around if they have a Zimmer frame; two of the bathrooms have assisted baths; the staff living in the home share the bathrooms and toilets. Part of the service users lounge is used for a staff area. The computer for the care plans and telephone is in this area. During the inspection staff were heard to be speaking to a Doctor about a service user in this area. The small lounge stores service users files and equipment. The lounges had some tables next to the chairs and some over the chair tables for service users to use. It was not possible to inspect if the actions as recommended by the occupational therapist have been completed, as the report was not made available. H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 The service users cannot be assured that the staffing provided is able to meet their needs. EVIDENCE: There is 4 care staff including the manager or deputy in the morning with 4 staff on in the afternoon, 3 staff from 7.30 to 10 pm and 2 night staff from 10 pm until 7.30am. Extra staff provided include, a cook, cleaner, kitchen assistant who work in the morning up to 1.30pm and a handyperson. The duty rota did not contain all staff working in the home and in what capacity. The manager is on the rota to provide 4 hours of entertainment Monday to Friday. A staff spoken with about the long day shifts said that they have 30 minutes break, although there were some days they did not take a break. There is no staff room, staff use the balcony area. One service user spoken with said, “Staff okay” then pointed out a staff member stating, “she’s a nice person on today”. Another commented that staff were “alright today”. Staff were heard and seen during the inspection to be courteous and respectful towards the service users. The home has some staff that have worked at the home for a considerable period of time who have been described by the manager as being a loyal staff group. All staff, in the areas needed for staff and service users health and safety, have not completed staff training. The staff-training matrix lists 6 of the 25 staff as having the NVQ level 2. The pre inspection questionnaire lists 8 staff having this qualification. Fourteen staff have left since the last inspection. H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 20 The total number of duty hours according to the residential forum is 774.92 the staffing provided is 551.5. The 2 staff files inspected contained all of the information required; both staff had been recruited via an agency and had received an induction. H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 21 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 36, 37 38. The service users live in a home where the management are failing to provide them with an acceptable service. EVIDENCE: The pre inspection questionnaire states that the home is directly supervised by the owner on a weekly basis, backed up by the clinical director of care when needed. The day-to-day running is provided by the manager and deputy, the team leaders supervise the care delivery. The manager was on the rota to provide 4 hours of activities for 4 days a week. It was noted that a particular staff member was on the rota working long days exceeding the working time directive, when asked if this was agreed by the worker, the director of care responded to the manager “have you not got …to sign it”. A comment from a relative in a comment card received in relation to the information they were given about their relative stated, “information and opinion differs in both accuracy and relevance”. H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 22 The responsible individual Mr Ernie Graham and the director of care have conducted regular regulation 26 visits, however these did not fully reflect the true picture of the home or where issues had been raised or noted such as staff raising concerns about the standard of care or information about service users these were not followed through or acted upon. Many of the items raised within the previous inspection reports have not been addressed. Staff stated that when they started they received supervision, they could not remember when their last supervision was, stating they received informal supervision as work closely with the manager. Staff spoke well of the manager one commenting, “Grace tries her utmost”. The areas concerning health and safety that need addressing are:--the toilet frames remain unfixed; the television in the lounge is place on a table that is too small and not secure enough; three of the service users bedrooms have fire exits routes through them, although a cupboard has been moved that was blocking the exit in all of the rooms there is not a clear path provided for service users to safely have a means of escape; the top of the stairs has a sloping ceiling, no warning signs were in place; the carpet in the corridor outside of the lift had bumps and ridges; the fenced panels in the area for service users to access part of the garden was not smooth to the touch and easily splintered. There is no staff room for staff that are on long day shifts to take a break, staff lockers are not provided for their personal belongings. Staff were seen not to adhere to infection control policies and procedures. Some of the items of furniture and equipment could not be cleaned properly, a commode had faeces on it and a bedroom was being cleaned that had faeces on the carpet. The files in the administrator’s office containing information on service users had still not been made secure. The files for service users are stored in the small lounge in a metal cupboard. Care plans are recorded on the computer system; service users have no access to these. The fire officer has not yet visited; the manager stated that they were on the list to be visited. A visiting professional consultant has conducted a fire risk assessment. The fire exit in a downstairs bedroom is now illuminated. The home had a copy of the new Kent and Medway Multi agency adult protection policy that had been revised in May 2005. H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 23 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 1 15 2 COMPLAINTS AND PROTECTION 1 x 2 2 2 2 2 2 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 1 2 x 1 x x 2 1 2 H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 24 Yes Are there any outstanding requirements from the last inspection? 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 OP 1 OP 2 Regulation 4 (1) (2) Schedule 1 Requirement The registerd person shall compile in relation to the care home a written statement referred to as the statement of purpose. An updated version of the service users guide to include all items identified during the last inspection. 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. The registered person shall ensure that unnecessary risks to health and safety of service users are identified and so far as possible eliminated. 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, Timescale for action Full version to be forwarded to the CSCI by 19th August 2005 Action plan to be received by the CSCI by 6th August 2005. Action plan to be received by the CSCI by 6th August 2005. Action plan to be received by the CSCI by 6th August 2005. Page 25 2. OP 7.2 OP 7 6 15 (1) 3. OP 7 3 13 (4) (c) 4. OP 7.4 15 (2) (b) (c) H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 revise the service users plan. 5. OP OP OP OP 8.1 8.7 8.11 8.13 12 (1) 13 (1) (b) 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. Records to be kept: details of any plan relating to the service user in respect of medication, nursing, specialist health care or nutrition. Action plan to be received by the CSCI by 6th August 2005. 6. OP 8.9 17 (1) (a) Schedule 3 (o) 7. OP 9 13 (2) 8. OP 12 16(2) (m) (n) 9. OP 14 12 (2) (3) Action plan to be received by the CSCI by 6th August 2005. The registered person shall make Action plan arrangements for the recording, to be handling, safe keeping, safe received by the CSCI administration and disposal of medication received into the care by 6th home. In that the actions are August 2005. followed as per the pharmacist letter following their inspection. The registered person shall Action plan consult service users about their to be received by social interests and make arrangements to enable them to the CSCI engage in local, social and by 6th community activities. Consult August service users about the 2005. programme of activities arranged ay or on behalf of the care home and provide facilities for recreation, fitness and training. The registered person shall so Action plan far as practicable enable service to be users to make decisions with received by respect to the care they are to the CSCI receive and their health and by 6th welfare. The registered person August shall for the purpose of providing 2005. care to the service users, and making proper provision for their health and welfare, so far as practicable ascertain and take Version 1.40 Page 26 H56-H06 S39813 The Priory V226082 050705 Stage 4.doc into account their wishes. 10. OP 18.1 OP 18.5 13 (6) (8) The registered person shall make arrangements by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. On any occasion on which a service user is subject to physical restraint, the registered person shall record the circumstances, including the nature of restraint. Subject to regulation 4 (3), the registered person shall not use the premises for the purposes of a care home unless, the premises are suitable for the purpose of achieving the aims and objectives set out in the statemend of purpose; 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. 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. The home provides private accommodation for each service user which is furnished and equipped to ensure comfort and privacy. In that the storage of items and equipment in rooms be addressed. That the use of Action plan to be received by the CSCI by 6th August 2005. 11. OP 19.1 23 (1) (a) Action plan to be received by the CSCI by 6th August 2005. Action plan to be received by the CSCI by 6th August 2005. Action plan to be received by the CSCI by 6th August 2005. 12. OP 21.3 23 (2) (j) 13. OP 22.1 16 (16) (2) (C) 23 (2) (n) 14. OP 24 16 (2) (C) Action plan to be received by the CSCI by 6th August 2005. Page 27 H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 15. OP 25.2 23 (2) (P) 16. OP 25.8 13 (4) (a) (C) 17. OP 26.1 16 (2) (k) shared rooms for service users who use commodes with those who do not use commodes be reviewed. The registered person shall having regard to the number and needs of the service users encure that, ventilation suitable for service users is provided in all parts of the care home which are used by service users. In that room 18 does not have an opening window. The proposal for a vent has not been done. 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 registered person shall keep the care home free from offensive odours. Action plan to be received by the CSCI by 6th August 2005. Action plan to be received by the CSCI by 6th August 2005. Action plan to be received by the CSCI by 6th August 2005. Action plan to be received by the CSCI by 6th August 2005. 18. OP 27.1 OP 27.3 18 (1) (a) 19. OP 27.2 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 appropriate for the health and welfare of service users. Regulation The home shall keep and 17 (2) maintain a copy of the duty Schedule roster of persons working at the care home, and a record of 4, 7 whether the roster was actually worked. Action plan to be received by the CSCI by 6th August 2005. Page 28 H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 20. OP 30.1 18 (1) (C) (i) 21. OP 33.10 10 (1) 22. OP 36.1 23. OP 37.1 OP 37.3 24. OP 38 Action plan to be received by the CSCI by 6th August 2005. 17 (1) (a) The registered person shall Action plan (b) (2) (3) ensure that records referred to in to be received by 15 (1) (2) paragraphs (1) and (2) are kept the CSCI up to date. That the Data Protection Act is followed in by 6th respect of confidentiality during August telephone calls made in the 2005. service users lounge. That the records of service users are kept secure in that the records relating to service users in the files in the administrators office; this remains an ongoing requirement. 12 (1) 4 The registered person shall Action plan (a) 13 (3) ensure that the care home is to be 16 (2) (j) conducted so as to promote and received by make proper provision for the the CSCI health and welfare of service by 6th users; in that the items identified August in the text are addressed. 2005. 18 (1) The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of the service users ensure that persons employed by the care home receive training appropriate to the work they are to perform. The registered provider and the registered manager shall, having regard to the size of the care home, the statement of purpose, and the number and needs of the service users carry on or manage the care home (as the case may be) with sufficient care, competence and skill. The registered person shall ensure that the persons working at the care home are appropriatly supervised. Action plan to be received by the CSCI by 6th August 2005. Action plan to be received by the CSCI by 6th August 2005. H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 29 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 OP 2 Good Practice Recommendations It is very strongly recommended that the home provede each service user with a statement of terms and conditions / contract. The contract that was contained in the service users guide was recommended during the last inspection to be more detailed and specify if the room was a single or double, include the fees payable and by whom and specify the category of service user as being either old age or dementia. No changes have been made. It is very strongly recommended that the pre-admission assessments are more comprehensive. It was not inspected if the service users had an inventory list of their personal effects that was checked and signed by the service user and or representative as identified during the last inspection.. It is strongly recommended that the service users who have declined in health and ability due to age and frailty have assessments updated as to their physial and mental needs. It is recommended that special attention is made to provide and maintain the dignity and respect of service users. It is recommended that links and involvement with the local community be made and maintained. It is again at this inspection strongly recommended that a review be made of the meal times/routine in that service users are not seated for an unacceptable period of time before lunch is served. It is recommended that service users are able to have tea in the dinning room. It is strongly recommended that the items identified in the building inspection report conducted on 14th August 2002, valid for 5 years are carried through. It is strongly recommended that the service users who currently share a room have the opportunity to choose not to share, and that service users from the mixed categories do not share a room. It is recommended that, where practicable, service users bedrooms be furnished as detailed. There was no evidence of this having been acted upon. It remains recommended that the laundry floor be made H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 30 2. OP 3 3. OP 8 4. 5. 6. OP 10 OP 13 OP 15 7. 8. OP 19.4 OP 23.7 9. 10. OP 24.2 OP 26.4 11. 12. 13. 14. OP 28.1 OP 31.6 OP 36.1 OP 37.2 impermeable. It is recommended that 50 of the care staff have gained the NVQ level 2 or equivalent by 1st January 2006. It is very strongly recommended that the job description of the manager to undertake leisure activities be reviewed so that it does not impinge on other duties. It is recommended that where staff have agreed to work over the working time directive the relevant disclaimer is signed on file. It is strongly recommended that service users have access to their records and information about them held by the home, as well as opportunities to help maintain their personal records. H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 31 Commission for Social Care Inspection The Oast, Hermitage Court Hermitage Lane Maidstone Kent 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 H56-H06 S39813 The Priory V226082 050705 Stage 4.doc Version 1.40 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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