Inspection on 06/10/06 for The Priory

This inspection was carried out on 6th October 2006.

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

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

Other inspections for this house

The Priory 10/02/10

The Priory 02/02/10

The Priory 20/10/09

The Priory 30/06/09

The Priory 02/12/08

The Priory 21/10/08

The Priory 08/07/08

The Priory 31/07/07

The Priory 02/03/07

The Priory 11/12/06

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 Keith Salmon Key Unannounced Inspection 6th October 2006 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.V315022.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.V315022.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 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 Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places The Priory DS0000064067.V315022.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 1 Qualified Nurse (RGN or EN) 6 Care Staff 14:00-22:00 1 Qualified Nurse (RGN or EN) 4 Care Staff 22:00-08:00 1 Qualified Nurse (RGN or EN) 3 Care Staff 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. 8th May 2006 Date of last inspection Brief Description of the Service: Situated on the eastern edge of the Shropshire town of Wellington, with local amenities available a short walk away, The Priory is a privately owned Care Home providing Nursing and residential care. Set in its own grounds, with a car park to the front, the building comprises a large converted town house with a purpose built ‘Nursing’ extension added in recent years, and is registered to provide care for a maximum of 37 residents 17 of which may require nursing care. The Priory DS0000064067.V315022.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This ‘Key’ Unannounced Inspection commenced at 9.30 a.m., concluded at 3.30 p.m. (a total 6 hours) and was conducted by Mr Keith Salmon. Present for the Home were, initially, Mrs. Barbara Johnston and later Mrs. Mel Thomson (Manager). This ‘Key’ Inspection was undertaken as an adjunct to a ‘Random’ Unannounced Inspection carried out, two weeks previously, on 22 September 2006. The combined inspection time was 11 Hours. At the ‘Random’ Inspection, held on 22 September, the Inspector was concerned to find little, if any, advancement in relation to ‘Requirements’ cited at the previous ‘Key’ Inspection, held on 8 May 2006. Areas of particular concern were staffing levels and lack of progress in providing improved laundry facilities. Therefore, it was decided to undertake this further more comprehensive and detailed Inspection to obtain a more robust assessment of the quality of care being provided to Residents. This Report is based on observations made during a tour of the Home, a review of care related documentation, staff duty rotas, staff files, plus a range of other documents/records reflecting the general operation of the Home. Over the course of the two visits the Inspector held 1:1 discussions with Mrs. Thomson, Mrs. Johnston, 10 Residents, 4 Visitors plus several members of Staff. What the service does well: What has improved since the last inspection? What they could do better: The predominant need is for the Home to meet the five previous unmet Requirements, and six new ‘Requirements’ arising from this Inspection, by the target dates. The Priory DS0000064067.V315022.R01.S.doc Version 5.2 Page 6 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 DS0000064067.V315022.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Priory DS0000064067.V315022.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. It is possible that, on occasions, insufficient care is exercised in ensuring the Home is able to effectively meet Residents’ care needs. EVIDENCE: During the Inspector’s first visit, a discussion with one Resident (female), reported that another Resident (male, suffering from dementia) frequently wanders into her room (and her neighbours room). The Resident has made Staff aware of this and they in turn ensure the door to the adjacent corridor is shut at night. However, the wandering Resident is able to open the door, and does so. The Inspector raised this matter with the Manager who accepts the Resident is probably inappropriately placed. Since that time the Resident has been admitted to the local general hospital and the Inspector was informed the Home is awaiting formal assessment by Telford and Wrekin Social Services Department with regard to the ‘appropriateness’ of future placement. The Priory DS0000064067.V315022.R01.S.doc Version 5.2 Page 9 ‘Case Tracking’ this Resident, which involved a Care Plan review, showed no evidence of formal pre-admission assessment. A wider review of other Care Plans showed a similar pattern, although those Residents admitted following hospital treatment did have discharge plans. It is understood that all prospective Residents are seen and assessed by the Manager or Senior Staff Member, as required by Regulation. However, the supporting documentation generated by the assessing member of staff was lacking in many instances. The Manager advised the Inspector that documentation is in the process of being changed to a new model (an example was seen by the Inspector) and this had led to Care Plans of recently admitted Residents, not being fully completed. A more formalised approach to pre-admission assessment is to be an integral part of the new care planning documentation. It is a ‘Requirement’ of this Inspection that, for all prospective Residents, a pre-admission assessment must be undertaken by a suitably trained/ experienced member of Staff, and written evidence retained within the Residents care planning documentation. The Priory DS0000064067.V315022.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The majority of Care Plans inspected provided a satisfactory basis for the delivery of care that effectively meet assessed needs. However, there has been a decline in the general standard of maintenance of care planning documentation, particularly in Residents who have been most recently admitted. The storage, administration, and disposal of medicines are in accordance with accepted good practice. ??THIS SOUNDS A BIT CONTRADICTORY TO PREVIOUS COMMENTS ABOVE. EVIDENCE: ‘Case Tracking’ involved a review of Care Plans/Files relating to nine Residents’, i.e. the three most recently admitted Residents, plus 6 selected at random, revealed that although Care Plans for longstanding Residents were found to be comprehensively completed with current entries, several gaps were found in Care Plans relating to recently admitted Residents, e.g. evidence of formal pre-admission assessment. The Acting Manager acknowledges this and advises that documentation is in the process of being changed to a new The Priory DS0000064067.V315022.R01.S.doc Version 5.2 Page 11 model. The Inspector was shown an example of the new documentation, which appears satisfactory. It is a ‘Requirement’ of this Inspection the proposed change to a new model of Residents’ Care Plan must be completed as soon as possible. The Home has Policies and Procedures for the management and administration of medicines, which are an integral part of the Home’s staff induction programme. Medicines are administered by means of a Boots monitored dosage system with regular support from a Boots pharmacist. The storage, administration, and disposal of medicines are in accordance with accepted good practice. The Inspector observed Staff relating to Residents, and their families/visitors, in a friendly and respectful manner. The Priory DS0000064067.V315022.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A limited range of leisure opportunities is provided, which are consistent with Residents’ capabilities. The Home facilitates achievement of desired lifestyle through Residents conducting the pattern of their day, where possible, as they wish, including contact with family and friends, and continuation of religious practices. There is a daily choice of meals from a menu offering traditional fare. The variety and quality offered has shown some improvement. EVIDENCE: The Home has improved the range of activities offered on site, which are led by a Carer who has additional responsibilities as ‘Activities Coordinator’. The main provision is by way of relatively brief, but frequent, activities focussed on meeting Resident’s capabilities, e.g. span of attention. However, as mentioned in the previous Inspection Report, there is a need to offer Residents more opportunities for trips and outings. Also, Residents informed the Inspector they greatly enjoyed the occasional visiting entertainers, a provision they would like to see more of. Residents expressed the view that they were generally satisfied with the quality of food provided. The Priory DS0000064067.V315022.R01.S.doc Version 5.2 Page 13 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home’s Management and Staff are receptive to issues and complaints raised by Residents and relatives/visitors. Generally, they are able to provide and implement an effective response. The interests of Residents are protected through ready access to information relating to advocacy services and the Home’s Complaints Procedure. Staff are aware of their role in protecting Residents from abuse. EVIDENCE: Complaints Procedure details are included in the Service User Guide and are displayed prominently for the benefit of visitors. There are policies and procedures in place intended to provide protection for vulnerable people. These fully meet the requirements of this Standard and Staff Training Files confirm the topic is covered at induction and through on-going staff training. The Priory DS0000064067.V315022.R01.S.doc Version 5.2 Page 14 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 & 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Some improvement in specific areas was evident in that a small number of first floor bedrooms, in the original building, have been redecorated. However, major concerns remain with regard to long-term plans for on-going refurbishment, redecoration, replacement of furniture and equipment, the amount of dining space available and laundry provision. EVIDENCE: Requirement relating to NMS 19: “The registered person must ensure that the floor covering is replaced in bedroom 29.” Inspection of bedroom 29 showed the room has been re-carpeted and the above ‘Requirement’ is fully met. The Priory DS0000064067.V315022.R01.S.doc Version 5.2 Page 15 A windowless room on the ground floor, which previously functioned as a dining room, is no longer in use for that purpose. It is accepted this action was taken due to the environment within the room being extremely unpleasant due to a strong, and enduring, smell of heating oil. Whilst the Inspector accepts this step was taken to ensure Residents are not exposed to unpleasant conditions, and, as such, is commendable, it has effectively reduced the amount of community space available to Residents. Therefore, as the original Registration of the Home was granted on the basis of dining space being available to Residents, it is a ‘Requirement’ of this Inspection that an equal, or increased sized, space is reinstituted. Proposals to achieve this must be made to the CSCI, for agreement, by the specified target date. The Requirement relating to NMS 26:“The Responsible Person must send to the CSCI, for approval, plans for increasing the capacity for the laundering of bed linen and Service Users’ personal clothing.” Previous target date of 12/06/05 remains unmet. Inspection of the laundry demonstrated there has been no action whatsoever in respect of the development of laundry services. To reiterate comments made in the Report following the Announced Inspection undertaken on 12/05/2005, the siting and capacity of the laundry are of serious concern, i.e. the laundry room is situated within the ‘Nursing’ Section of the Home, thus requiring movement of soiled linen from the ‘Residential’ to the ‘Nursing’ section. In addition, the laundry facility comprises one washing machine and one drying machine with no back-up facility should a machine fail. Both of these aspects present serious opportunity for the spread of infection. Furthermore, at peak periods of activity the laundry room does not offer adequate floor space for the reception, sorting and onward management of linen and clothing, with a resultant overloading of the system and a ‘backlog’ of soiled linen. All of these factors contrive to present a major infection control risk. The Requirement, relating to this shortfall, remains in force. The Priory DS0000064067.V315022.R01.S.doc Version 5.2 Page 16 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. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff numbers on duty and skill-mix are not sufficient to meet the assessed care needs of current Residents. Recruitment and employment practices are consistent with the safeguarding of Residents. The on-going provision of training for Care Staff, in accordance with individual Staff Member’s learning needs, has declined and is currently only satisfactory. EVIDENCE: Discussions held with Residents and Visitors produced mixed comments relating to Staff, including – on the positive side - “…they look after us very well”, “…I like being here”, but more critically “…the staff seem under much more pressure than they used to be,” “…they (the staff) don’t respond as quickly as they should.” These latter comments, together with comments by members of Care Staff regarding increased work pressures to which they felt exposed, beg questions about the levels of staffing within the Home – a matter already addressed by a ‘Requirement’ cited at the immediately preceding Inspection, i.e. “The registered person must ensure care staff be increased by two full staff in the daytime.” The Priory DS0000064067.V315022.R01.S.doc Version 5.2 Page 17 This was deemed necessary due to the increased dependency levels of several Residents. This ‘Requirement’ has not been met – indeed scrutiny of current Staff duty rotas, and those from the immediately preceding months, demonstrated Staff numbers and skill-mix are frequently not in accordance with the minimum requirements of item two of the Home’s ‘Conditions of Registration’. This states: ‘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.’ Specifically this Notice requires that each day staffing numbers and skill-mix must be as follows: During the period 08:00 to 14:00 there will be on duty a minimum of 1 Qualified Nurse (RGN or EN) and 6 Care Staff. During the period 14.00 to 22.00 there will be on duty a minimum of 1 Qualified Nurse (RGN or EN) and 4 Care Staff. During the period 22:00 to 08:00 there will be on duty a minimum of 1 Qualified Nurse (RGN or EN) and 3 Care Staff. A detailed review of the months of July, August and September 2006, demonstrated staff cover, as indicated on the ‘working’ copy of the staff duty rotas, failed to meet the minimum staffing requirements as follows: The minimum required level of staffing was achieved for only: 37 of shifts 0800 to 1400 22 of shifts between 14.00 and 17.00 47 of shifts between 17.00 and 22.00 55 of night shifts. An inspection of account dockets, reflecting the use of agency staff, suggested some reduction in the failure to meet Conditions of Service to some small degree. However, there is a serious concern that staffing levels persistently fail to meet the levels set out in the Staffing Notice, which is a Statutory Notice and must be adhered to, i.e. the levels, and mix of staffing, as set out in the Staffing Notice, must be provided, as the minimum, for 100 of shifts. The Priory DS0000064067.V315022.R01.S.doc Version 5.2 Page 18 Furthermore, the Staffing Notice states:‘Additional staff must be on duty when high dependency service users are accommodated’. At the time of this Inspection a review of Care Plans, relating to Residents in the ‘Nursing’ Section of the Home, showed there were a number of Residents who could be adjudged ‘high dependency’. It is of further concern that, not only were the minimum staffing requirements not always met, but also there was no evidence that the need for additional staff had been considered in order to meet this increase in dependency. Thus, it is a ‘Requirement’ of this Inspection that the Responsible Person takes effective action to ensure aforementioned ‘Conditions of Service’ are met with immediate effect. ‘Requirement’ relating to OP 29, Regulation 18 (a) “The registered person must ensure that the home achieves the minimum standard regarding the number of N.V.Q. trained Care staff. Target date 09/07/06.” The Home has shown a marked improvement in this area. Of the 26 Care Assistants, currently employed by the Home, 11 have attained NVQ Level III, with 4 having attained NVQ Level II. This combined total represents 58 of the Care Assistant workforce. Therefore, at the time of this Inspection, the ‘Requirement’ is met. The Priory DS0000064067.V315022.R01.S.doc Version 5.2 Page 19 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 & 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Operational (day to day) management of the Home is satisfactory. However, strategic (long term) management, including effective response to longstanding Requirements, is poor. General observation of day-to-day management indicates the Acting Manager has developed management capability during her time in post and displays strong commitment. However, regular presence of the Responsible Person (or appointed representative), at the Home to provide support to the Acting Manager, and to monitor quality of service provision, is lacking. Residents are at risk due to some health and safety and infection control practices. EVIDENCE: Requirements relating to the ‘Management and Administration’, cited at previous Inspections, have not been met and remain outstanding, i.e. The Priory DS0000064067.V315022.R01.S.doc Version 5.2 Page 20 ‘Requirement’ relating to OP 31, Regulation 9-(1)(2):“The Acting Care Manager must make application to the CSCI to be approved as Registered Matron/Manager.” Target date 09/07/06 unmet. The Manager informed the Inspector that one written application has been made to the CSCI for approval as Registered Manager. However, the application/approval process has not progressed due to the accompanying fee cheque being unsatisfactory. The Acting Manager is ‘Required’ to renew the application with immediate effect. ‘Requirement’ relating to OP 33, Regulation 24 (1) (a) and (b):The registered person must ensure that a Quality Assurance system is implemented within the Home to ensure the views of residents, relatives and other Professionals, on the service, are obtained and an action plan drawn up to address any issues raised. Target date 06/07/06 unmet. The Inspector was informed the previously established practice of using Questionnaires, to sample the views of ‘stakeholders’, had not been undertaken for some time. During the Inspection the following additional matters of concern, relating to this ‘Outcome Group’, were noted by the Inspector and are subject to new ‘Requirements’: The laundry, which was unattended, was found to be unlocked. On checking it was evident the laundry door has no facility for locking. The Inspector observed a large open packet of detergent situated on the floor, readily accessible to passing Residents, some of whom have dementia related illness – this presents a serious health and safety hazard. There was no evidence of visits to the Home by the Responsible Person, or other designated employee of the Organisation, as required by Regulation 26. The Priory DS0000064067.V315022.R01.S.doc Version 5.2 Page 21 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 2 X X X X X 1 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 1 The Priory DS0000064067.V315022.R01.S.doc Version 5.2 Page 22 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 OP3 Regulation 14. – (1), (a)(b) (c)(d) Requirement The Responsible Person must ensure that for all prospective Residents, a pre-admission assessment is undertaken by a suitably trained/ experienced member of staff, and written evidence retained within the Residents care planning documentation. The Manager must ensure that the proposed change to a new model of Resident’s Care Plan must be completed as soon as possible. The activities programme is to be reviewed and extended to include availability of outdoor trips etc and to take account of Service Users’ wishes. The Registered Person must provide the CSCI with a plan for redecoration/refurbishment, together with a programme, which includes dates for commencement and completion of work. Previous target date (12/06/05.) unmet. DS0000064067.V315022.R01.S.doc Timescale for action 30/11/06 2. OP7 15. – (1) 30/11/06 3. OP12 12. – (1)(a) 30/11/06 4. OP19 23. (2)(b)(d) 30/11/06 The Priory Version 5.2 Page 23 5. OP20 23. (2) (e) 16.(2)(e)(f) 6. OP26 7. OP27 18.(1)(2)(3) 8. OP31 9.-(1)(2) 9. OP33 26. (2)(3)(4) (5) 24 (1) (a) and (b) 10. OP33 11. OP38 12. (1) (a) The Registered Person must ensure the Home has sufficient dining room(s) to cater for all ‘Service Users’. The Registered Person must send to the CSCI, for approval by the Inspector, plans for increasing the capacity for the laundering of bed linen and Service Users personal clothing. Previous target date referring to staffing (12/06/05) unmet. The Registered Person must ensure staffing levels, and skillmix are in accordance with the ‘Conditions of Service’. Previous target date (06/07/06) unmet. The Acting Care Manager must make application to the CSCI to be approved as Registered Matron/Manager. Previous target date (09/07/06) unmet. The Registered Person must visit the Home and submit related reports of the visits in accordance with Regulation 26. The Registered Person must ensure that a Quality Assurance system is implemented within the Home to ensure the views on the service are obtained from Residents, Relatives and other Professionals, and an action plan drawn-up to address any issues raised. Previous target date (12/06/05.) unmet. The Registered Person must ensure that a lock is provided to the laundry door, to prevent access by Residents when the laundry room is unattended. 31/01/07 17/11/06 30/11/06 31/10/06 31/10/06 30/11/06 31/10/06 The Priory DS0000064067.V315022.R01.S.doc Version 5.2 Page 24 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. 2. 3. Refer to Standard OP19 OP34 OP34 Good Practice Recommendations That consideration is made of the provision of a ‘walk-in’ shower. That the Company’s policy on the payment of salaries is reviewed and circulated to all Staff. That the policy on the delegation of budgets is reviewed to allow the Manager greater autonomy. The Priory DS0000064067.V315022.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 DS0000064067.V315022.R01.S.doc Version 5.2 Page 26 - 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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