Inspection on 08/05/06 for The Priory

This inspection was carried out on 8th May 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 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 31/07/07

The Priory 02/03/07

The Priory 11/12/06

The Priory 06/10/06

The Priory 14/11/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Priory Springhill Wellington Telford Shropshire TF1 3NA Lead Inspector Mr Ian Harris Unannounced Inspection 8th May 2006 09:00 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.V292353.R01.S.doc Version 5.1 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.V292353.R01.S.doc Version 5.1 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.V292353.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Priory Nursing and Residential Home may provide care for a maximum of 37 older people, of whom up to 25 may require low to medium dependency nursing care. Staff involved iin the care of Residents must be suitably qualified, competent and experienced persons who are deployed in such number/skill-mix so as 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 2. 3. NB - additional staff must be on duty when high dependency service users are accommodated - these minimum levels are for direct nursing and personal care only, ie - they do not include ancillary staff. The above numbers may include the Manager when he/she is engaged in direct care provision, but are exclusive of the Manager when he/she is carrying out managerial duties. 14th November 2005 Date of last inspection Brief Description of the Service: The Priory is a privately owned care home providing Nursing and residential care. It is situated on the eastern edge of the Shropshire town of Wellington, With local amenities available a short walk away. The Building comprises of a large converted town house with a purpose built ‘Nursing’ extension add in recent years. The home is set in its own grounds and has a car park at the front of the building. The home is registered to provide care for a maximum of 37 residents 17 of which may require nursing care. The Priory DS0000064067.V292353.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a Key unannounced inspection and took place over 6.5 hours. The fullest, co-operation was given to the inspection officer by the Acting Care Manager, staff and residents. During the inspection a tour of the premises took place and staff and care records were inspected. Also staff rotas and general records regarding the maintenance of the home were checked. 7 of the 40 care staff were on duty, and 6 of the 34 residents were spoken to. After a period of disruption of a change of ownership the home is settling down. The new owners have commenced a programme of refurbishment and redecoration that has already made an impact on the moral of staff and the quality of the environment. On the day of inspection the atmosphere within the home was found to be warm, friendly and comfortable with contented residents. What the service does well: What has improved since the last inspection? Considerable amount of internal re-decoration has taken place since the last inspection. Five residents bedrooms and two bathrooms have been refurbished and redecorated. The designation of a member of staff to organised social activities has improved the quality of live for the residents. Also improvements have been made to staff files and resident’s files. The Priory DS0000064067.V292353.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Priory DS0000064067.V292353.R01.S.doc Version 5.1 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.V292353.R01.S.doc Version 5.1 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 and 6 Appropriate assessments of need are in place and are carried out. The home does not provide intermediate care. EVIDENCE: There is evidence on the files that all the residents who are funded by the Local Authority undergo a full multi-disciplinary assessment prior to admission. Any residents, who are self funding are assessed by the Care Manager, using the homes assessment forms. All residents are encouraged to visit the home prior to admission. However it was noted that on occasions the visits are declined and relatives visit the home on behalf of the prospective resident prior to admission. A trial period is included in the statement of terms and conditions of residence and the homes contracts and is discussed with the residents and their relatives at the time of admission. All the residents are permanent. The home does not provide intermediate care. The Priory DS0000064067.V292353.R01.S.doc Version 5.1 Page 9 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, and 10 Each resident has a comprehensive, individual care plan that is reviewed on a monthly basis. The home has good contact with local G.P. s. local hospitals and paramedical services, which ensures that resident’s health needs are met. The systems for the administration of medication are good with clear and comprehensive recording arrangements are in place to ensure resident’s medication needs are met. EVIDENCE: The home provides a care plan for each resident based on the initial assessment .The care plans are drawn up by staff with consultation with the resident and their family. There was evidence on file to show that the care plans are reviewed on a monthly basis. Residents confirmed that they felt that they are receiving good health care. The home is well supported by local G. P.’s and all paramedical services. Where possible the residents are encouraged to retain their own G. P.’s, Dentists and Opticians. However if a resident has moved outside of their area, The Priory DS0000064067.V292353.R01.S.doc Version 5.1 Page 10 the Care Manager ensures, that these services are provided by local practitioners. Medication is administered by means of a Boots monitored dosage system. The system has improved and is now working well. The home receives good support from a Boots pharmacist, and the Nursing Staff are trained in the system before they are allowed to administer medication. The home does have policies and procedures, which are an integral part of the homes staff induction programme. The Priory DS0000064067.V292353.R01.S.doc Version 5.1 Page 11 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 and 15 The home has improved the range of activities within the home, however there is a need to offer the resident more opportunities of trips and outings outside the home. The meals in the home are good, offering both choice and variety and also catering for special dietary needs EVIDENCE: The home has now appointed a designated member of staff who arranges social and leisure activities. This has proved successful and relatives are invited to join in with the residents at lease once a month. A number of residents said they enjoyed these arranged activities. It was noted that there have not been any outings or trips arranged since Christmas. The Acting care manager stated that it was becoming increasingly difficult to encourage residents to go out on trips this was confirmed by residents when asked about outings. Most resident have good contact with their relatives and a small number of residents go out with their family on a regular basis. Family and friends are welcomed at the home and are invited to attend parties and other celebrations activities arranged by the home. The observations made, examination of menus and the comments received from the residents and their relatives confirmed that particular attention is The Priory DS0000064067.V292353.R01.S.doc Version 5.1 Page 12 given to the residents’ individual preferences regarding meals. Comments made by residents regarding the quality, quantity and variety of food provided were highly complimentary. The Priory DS0000064067.V292353.R01.S.doc Version 5.1 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 and 18 The Home’s Management and Staff are receptive to issues and complaints raised by Residents and relatives/visitors, and, generally, are able to provide and implement an effective response. Residents are protected from abuse by the home’s policies and procedures EVIDENCE: The home has a comprehensive complaints procedure. The residents and relatives are made aware of the procedure through the statement of their terms and conditions of residence and a notice on the notice board in the hall. The home has a complaints book in which all complaints are recorded. It was noted that there have been no formal complaint since the last inspection and all minor complaints are dealt with appropriately and quickly. The home has good policies and procedures regarding Restraint, dealing with Aggressive Behaviour and Prevention of Abuse, which includes, a WhistleBlowing policy. These issues are also covered in the N.V.Q. training, which the Staff are undergoing. There have been no incidents that have needed to be recorded or reported. The Priory DS0000064067.V292353.R01.S.doc Version 5.1 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 and 26 The standard of the environment within the home and the garden has greatly improved providing the residents with an attractive, comfortable, homely and safe place to live. However there are still areas in the old part of the building that need refurbishing. The residents would benefit from the provision of a walk in shower. The standards of cleanliness, tidiness, odour control and infection control practices throughout the Home were generally good. However, the Home’s laundry provision is insufficient and poses an infection control risk. EVIDENCE: The Priory DS0000064067.V292353.R01.S.doc Version 5.1 Page 15 It is acknowledged that considerable improvements have been made to the environment of the home and work is continuing to make further improvements Since the last inspection a further 5 bedrooms have been redecorated and refurbished and new floor covering has been fitted to the bathrooms. Future refurbishment should focus on the first floor of the old part of the building and the carpet in room 29 must be replaced as in posses a danger to the residents. The Home has a laundry room comprising one washing machine and one drying machine, with no back up facility should a machine fail. The room is situated within the ‘Nursing’ Section of the Home, thus requiring movement of soiled linen from the ‘Residential’ to the ‘Nursing’ part of the Home, and presenting a serious opportunity for the spread of infection. In addition, at peak periods 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 ‘back-up’ of soiled linen - presenting a further infection control problem. The home has very good hygiene and infection control policies and all the care and catering staff have undergone Food Hygiene training .The domestic staff have undergone C.O.S.H.H. training. All staff are conscious of the risks of cross infection. The Priory DS0000064067.V292353.R01.S.doc Version 5.1 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, and 30 The home needs to increase the care staff to a level that ensures that service users’ needs are met at all times. The home has good policies and procedures regarding the recruitment of staff, which includes all the appropriate checks and references. There is a good training programme in place that ensures the staff are competent to do their job EVIDENCE: The current Staff duty rota, and those from immediately preceding weeks, were examined, and demonstrated staff numbers and skill-mix to be in accordance with the Statutory Staffing Notice. However since the Recent increase in the number of nursing beds and the increased dependency levels of a number of residents the care staff should be increased by 2 fulltime care staff. There are good written policies and procedures regarding recruitment of staff. The Care Manager is aware of the procedures to obtain police checks etc. and it was noted that the homes company have registered with an agency in order to carry out the appropriate checks. There was evidence in the staff files that all the appropriate checks have been undertaken. All staff at the home are committed to developing their knowledge and skills through training and have regular opportunities to do so through external and internal training activities. The home has a programme of N.V.Q. training and is working towards the minimum standard. Also the care staff have attended The Priory DS0000064067.V292353.R01.S.doc Version 5.1 Page 17 courses on Safe handling of medication, Moving and handling, First Aid, and Fire Prevention. The Priory DS0000064067.V292353.R01.S.doc Version 5.1 Page 18 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 and 38 The Home is well managed on a day to day basis by Acting Care Manager. All Staff are contributing to ensuring that Residents’ best interests are served. However, the Standard is not met, as the Home still does not have a Matron/Manager formally Registered with the CSCI, as required by Regulation 9. ‘Health and Safety’ matters are conducted satisfactorily. EVIDENCE: The Care Manager is a qualified nurse and has considerable experience in caring for older people, both in nursing and residential home settings. There are clear lines of accountability within the home. The Care Manager has regular supervision meetings with the proprietor. Observations made and discussions with residents and staff indcated that the Care Manager is very approachable and operates an open door policy. The The Priory DS0000064067.V292353.R01.S.doc Version 5.1 Page 19 staff and residents stated that they are happy to approach the Care Manager with any problems they might have. All the records and administrative procedures within the home that were inspected, were found to be well maintained. However it was noted that the home has not implemented a Quality Assurance system to obtain feedback on the service they provide. Also the provision of a computer for the officer would be a great advantage and free up the manager from cumbersome admin. The home has a good heath and safety policy and all staff are aware of their responsibilities regarding these issues and a number of staff have received training. Fire fighting equipment is well maintained and the systems are regularly checked. In regards to any accidents, they are all recorded in an appropriate record book. The Priory DS0000064067.V292353.R01.S.doc Version 5.1 Page 20 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 3 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 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X 3 The Priory DS0000064067.V292353.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? The Priory DS0000064067.V292353.R01.S.doc Version 5.1 Page 22 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 OP29 Regulation 18 (a) Requirement The registered person must ensure that the home achieves the minimum standard regarding the number of N.V.Q. trained Care staff. That the Acting Care Manager must make application to the CSCI to be approved as Registered Matron/Manager. The registered person must commence and complete the work to increase the laundering capacity, within an agreed timescale. Previous target date (12/05/05) unmet. Timescale for action 09/05/06 2. OP31 9.-(1)(2) 09/05/06 3. OP26 16.(2)(e)(f) 09/05/06 4. OP26 16.(2)(e)(f) The registered person must send 09/05/06 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 (12/05/05.) unmet. 01/06/06 5 OP19 23 (2)( c ) The registered person must ensure that the floor covering is replaced in bedroom 29 The Priory DS0000064067.V292353.R01.S.doc Version 5.1 Page 23 6 OP27 18 (1) 7 OP33 24 (1) (a) and (b) The registered person must ensure that the care staff is increased by two full staff in the day time. The registered person must ensure that a Quality Assurance system is implemented within the home to ensure that residents, relatives and other Professionals views on the service are obtained and an action plan drawn up to address any issues raised. 01/07/06 01/07/06 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. Refer to Standard OP31 OP19 Good Practice Recommendations That a computer is provided for the office. That consideration is made of the provision of a walk in shower. The Priory DS0000064067.V292353.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE 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.V292353.R01.S.doc Version 5.1 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!