Inspection on 17/04/08 for The Priory [Tetbury]

This inspection was carried out on 17th April 2008.

CSCI found this care home to be providing an Adequate service.

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 [Tetbury] 02/05/06

The Priory [Tetbury] 31/10/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE The Priory The Chipping Tetbury Glos GL8 8ET Lead Inspector Sharon Hayward-Wright Unannounced Inspection 11:20 17 & 18th April 2008 th 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 DS0000064595.V359663.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 DS0000064595.V359663.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Priory Address The Chipping Tetbury Glos GL8 8ET 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) 01666 502332 01666 502332 tess.edwards@somersetcare.co.uk Somerset Care Limited Theresa Ann Edwards Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places The Priory DS0000064595.V359663.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd May 2006 Brief Description of the Service: The Priory Nursing Home is situated close to the centre of Tetbury, with many amenities within walking distance. The property is owned by the National Benevolent Institution (NBI) and is under the management of Somerset Care. The home accommodates 30 older people for nursing care. A registered general nurse is on duty twenty-four hours each day, and there are waking night staff. All health care services are available, and people are able to choose their General Practitioner from within the locality. The accommodation offered is spacious, tastefully furnished and decorated to a high standard. The communal areas are all on the ground floor and include a large hall with comfortable seating areas, two large lounges, a library, a spacious dining room and a conservatory overlooking an attractive walled garden with raised beds and a water feature. The accommodation is set on three floors accessed by stairs, a shaft lift and a stair lift, and currently has twenty-eight single rooms, two of which can be used to provide shared accommodation if particularly requested by a couple. Assisted bathing and toilet facilities are also available on each floor. The fee ranges are from £544.20 to £850 per week. The home is going to provide people who are eligible for the Funded Nursing Care Contribution (FNC) with information about how they manage this payment. The home has copies of their Statement of Purpose and Service Users Guide available in the main entrance. The Priory DS0000064595.V359663.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. One Inspector carried out this inspection over two days in April 2008. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes in to account the views and experiences of people using the service. The Registered Manager was available during the inspection as were other members of the homes team. A total of 26 standards were inspected. The home returned their detailed Annual Quality Assurance Assessment (AQAA) following this inspection. Some information from this has been used in this report. Where possible, people living at the home were spoken with to ascertain their views on the care and services provided and any visitors to the home. Surveys were sent to the home prior to the inspection for people who use the service, their relatives/representatives and staff. We received eight surveys from people who use the service, three from relatives/representatives and one from a General Practitioner (GP). Their responses have been used in this report. Staff were observed interacting with people who use the service. The comments we also received from speaking to people during the inspection have been used in the report. The home has one requirement that has not been met for the last two inspections. Unmet requirements can potentially place people who use the service at risk and must now be addressed as a matter of urgency. What the service does well: The home has procedures in place to ensure prospective people are assessed prior to admission to make sure the home can meet their needs. Prospective people and their family/representatives have the opportunity to visit the home and assess it for its suitability prior to the person moving in. The Priory DS0000064595.V359663.R01.S.doc Version 5.2 Page 6 The home offers people who use the service a varied activities programme should they wish to participate, otherwise they are free make their own arrangements. There are no restrictions on visiting to the home. Dietary needs of people who use the service are well catered for, with a balanced and varied selection of food available that meets people’s tastes and choices. The Priory provides people with a pleasant and clean environment to live. It is decorated to high standards and there are plans in place to continue with the redecoration and refurbishment programme. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Priory DS0000064595.V359663.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 DS0000064595.V359663.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 5 & 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The admission process used by the home makes sure that people who may use the service receive a full assessment and assurance their needs will be met. EVIDENCE: Copies of the homes Statement of Purpose and Service Users Guide are available in the home and their Annual Quality assurance Assessment (AQAA) states theses guides can be provided in other formats to include Braille. Since the last inspection several amendments to the Care Home Regulations 2001 have taken place and one includes how people who use the service can access additional services and how they pay for them. The home must now include this in their Service Users Guide. At the last inspection the home was waiting for guidance from the Department of Health in relation to the Funded Nursing Care Contribution (FNC) in how to manage this process. At this inspection the home was able to provide copies The Priory DS0000064595.V359663.R01.S.doc Version 5.2 Page 9 of invoices to people who use the service that showed the break down in fees and how much the FNC contribution is. However the home has not provided information to people who use the service or their representative on how they manage this contribution. The pre admission assessment one person admitted since the last inspection was examined. As this person was in a hospital that was too far away for the Registered Manager to visit, the Registered Manager had spoken to the hospital, had obtained written information from the hospital and this person’s family had contacted the home. The home sends out to people or their family/representative a letter confirming the home can meet their needs and the Registered Manager said she sends with this a copy of the assessment/care plans she has devised, but the home do not keep a copy of this. The home must now keep a copy of this assessment to demonstrate they can meet the needs of the proposed person. This person was not able to visit the home prior to moving, however another person who was new to the home was spoken to and they had visited the home after their family had viewed it and were very happy with the choice they made. In the surveys we received from people who use the service seven people said they had received enough information about the home prior to moving in and one person said no as they were admitted quickly from hospital. Three surveys were received from relatives of people at the home all said they had enough information to be able to make a decision about if the home was suitable. Standard 6 is not applicable to The Priory, as they do not provide intermediate care. The Priory DS0000064595.V359663.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs and choices. The staff make sure that the principles of respect, dignity and privacy are put into practice. EVIDENCE: The care of two people who use the service was examined in detail. This included reading care records, speaking to staff members and where able speaking to the person. The two people were chosen at random during the inspection. At the last inspection it was identified that ongoing assessments of need were not always kept up to date. At this inspection one of the two people whose care was examined in detail had not had theirs reviewed since February 2006. The Registered Manager and a company representative stated that a new computer care planning system is due to be implemented very shortly and this will address the issue of ongoing assessment of needs. The homes Annual Quality Assurance Assessment (AQAA) states that as well as the new careThe Priory DS0000064595.V359663.R01.S.doc Version 5.2 Page 11 planning format they want to encourage more input from people into their care plans. Each person had very detailed care plans in place that listed exactly the care the staff need to provide and included people’s choices, this is excellent practice. Evidence of reviews was also seen. Assessments were in place for each person in relation to moving and handling, pressure sores, falls and nutrition; again reviews were seen for each of these assessments. ‘Body charts’ were in place for people who had wounds, however these were not examined at this inspection, as both people did not have any wounds. On checking the pressure relieving mattress for one person it was noticed that it was set too high for this person. The nurse was informed and this was addressed immediately. Staff need to make sure they check this throughout the day because if the mattresses is set too high it could lead to skin damage. Records are maintained of any health professional visits and any communication with relatives. One person who has their care examined in detail was spoken with and they were very happy with the care they receive. Of the eight surveys we received from people who use the service, four people said they ‘always’ receive the care and support they need and four people said ‘usually’. Of the three relative surveys we received two said their relative ‘always’ receives the care and support they need and one said ‘usually’. One person who uses the service had made a comment “the staff are sometimes slow to respond due to shortages but they receive very good care”. We also received a survey from one of the local GP surgeries and they said they are satisfied with the overall care provided by the home. Medication systems used by the home were inspected. Only qualified nurses administer medication. Records were seen of medication received, administered and where necessary returned to the homes supplier. The home has a contract in place to return any medication. Records were also seen of controlled medication and the audits that the home carries out for this medication. The home has arrangements in place to store medication securely and they use a lockable trolley to transport medication around the home. All Medication Administration Records (MAR) were examined and it was noticed that gaps in the recording were found on one person’s MAR for two days at the evening dose for one type of medication. The nurse on duty was going to investigate this. Hand written entries were checked and signed by a second member of staff, which is good practice. Care plans were in place for the two people that had their care examined in detail and that required ‘as and when needed’ medication. However one care plan required more detail about when they would be given. An audit was undertaken of one person’s medication as they were taking antibiotics. This includes counting the medication against the records they have The Priory DS0000064595.V359663.R01.S.doc Version 5.2 Page 12 for when they received it, counting the tablets and checking how many signatures were on the MAR. Six doses were signed for but only five tablets were missing from the packet. The home need investigate this and look at ways of preventing this from happening again. A specimen signature list was seen as well as an up to date drug reference book and fridge temperatures. Dates of opening were seen on liquid medications and boxed medication that was stored in the trolley. The home has a homely remedy list that is signed by the local GP’s; this was last done in October 2004. Consideration should be given to this being reviewed by the GP’s to ensure people who use the service can still receive this type of medication along with their prescribed medication. One-person self-medicates but this was not examined at this inspection as no issues were identified at the last inspection. Staff were observed treating people who use the service with respect for example knocking on their door prior to entering. People who use the service said the staff were very good to them and no concerns about the staff conduct were expressed. The Priory DS0000064595.V359663.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their life style and the home provides a varied activities programme to meet people’s recreational interests. EVIDENCE: The home devises a monthly newsletter detailing the activities happening that month. Copies of these were seen in the main reception area of the home. The activities provided include group activities, one-to-one and outings. People who use the service that were spoken with said they are able to choose whether they join in the activities provided. One person said they are too busy doing their own activities to join in the ones provided by the home, as they are able to go out alone into the local town. This person also confirmed that they are able to maintain their spiritual needs. One person said that the hairdresser visits the home every Tuesday. An outing was taking place during the inspection. One person spoke very highly of the activities coordinators. The Priory DS0000064595.V359663.R01.S.doc Version 5.2 Page 14 The feedback on the eight surveys we received back from people who use the service about activities said; one person said they do not join in as they prefer to make their own activities, four people said they ‘usually’ take part in the activities provided but two of these said that at times due to mobility issues they are not able. One person said ‘sometimes’ due to their medical condition. People who use the service and staff confirmed there is no restriction on visiting to the home. Links with the community are maintained, for example a local ‘quilting club’ are meeting at the home and one person said they are able to go out to a local coffee morning. People where able can make choices about their daily lives and information about advocacy services is available on the notice board outside the Managers office. People who use the service said they can choose how to spend their time each day and this includes where they want to eat their meals, as several people said they prefer to eat their meals in their rooms. Peoples personal possessions were seen on display their rooms. One of the cooks said the home operates a four-week menu rotation. They have a winter and summer menu that is devised by the company that owns the home. The menus showed that the home offers choices at each meal and people spoken with confirmed this. One person had an alternative to the lunchtime meal on the second day of the inspection. The home is able to cater for people who need special diets. A mealtime was observed and a meal tasted. Several people had alternatives to the menu and the meal tasted delicious and very well presented. One person in the dining room required assistance and this was offered in a sensitive manner. The main dining room is maintained to very high standards and nicely presented for meal times. The cook said that home made cakes are provided for afternoon drinks for people and this was observed. Drinks were seen being offered to people at intervals during the day. Health and safety checks are in place and records are maintained of the food provided. People spoken with said how much they enjoy the food provided by the home. The feedback we received on the surveys said; four people said they ‘always’ enjoy the food provided, three people said ‘usually’ and one person said ‘sometimes’ but they commented “I am not interested in food but it could be made more interesting”. The Priory DS0000064595.V359663.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service and their representatives are able to express their concerns and have access to a complaints procedure. Policies and procedures are in place to protect people, however these have not always been followed on every occasion. EVIDENCE: The homes AQAA stated that since the last inspection the home has received six complaints. One complaint was sent to us and forwarded on to the company to investigate. Records and letters relating to these complaints were seen. One complaint had come from a member of staff and the company had chosen to investigate it under employment law, all records relating to this were in place and the staff member was happy with the outcome. As the complaint was written consideration should be given to also providing a written response. The Registered Manager says she operates an ‘open door policy’ and encourages people who use the service, their relatives and staff to speak to her if they have any concerns. People spoken with during the inspection all said they did not have any complaints. A copy of the homes complaint procedure is in their Statement of Purpose and Service Users Guide and copies of these are in the main entrance. The Priory DS0000064595.V359663.R01.S.doc Version 5.2 Page 16 The results in the surveys we received from people who use the service said that six people know how to make a complaint and two people said they didn’t know how to make a complaint. In the surveys we received from relatives two said ‘yes’ they know how to make a complaint and one said ‘no’ they didn’t know how to make a complaint. All three people said that the home ‘always’ responds appropriately to concerns about peoples care. The Registered Manager provides the training for staff in relation to abuse and POVA. She uses a training pack provided by an outside provider and all questionnaires completed by staff are sent off to them for marking. This training includes information about local reporting procedures if an allegation of abuse is made. The Registered Manager is planning to undertake this training shortly with all staff. The home has copies of the ‘Alerters’ guide, which is on the notice board next to the Registered Manager office. None of the staff or the Registered Manager has undertaken the training provided by the local council in relation to abuse and the reporting procedures and consideration should be given to booking staff where able on to this training. The home has policies and procedures in place in relation to abuse’ whistle blowing, use of restraint, Mental Capacity Act, bullying and aggression towards staff. From the evidence seen staff are aware of the importance of whistle blowing and reporting any unsafe practice they might witness by other members of staff. On checking recruitment files on staff that have started at the home since the last inspection it was found that one member of staff was working at the home for a couple of months prior to a POVA first check being returned. This is unsafe practice as it places people who use the service at risk. The Registered Manager and company representative felt this was an oversight on their part as a Criminal Records Bureau Disclosure (CRB) had been sent for and this had not happened to any other staff that has started at the home. The Priory DS0000064595.V359663.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 & 26 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. With the continued investment in the home people live in a safe, comfortable and well–maintained environment that is adapted where possible to meet their needs. EVIDENCE: A tour of the premises took place and a number of people’s rooms were seen. The environment is maintained to high standards and since the last inspection several bathrooms have been marked to be turned into ‘wet rooms’. This was going to be completed the week following the inspection. At the present time the home are waiting for NBI who own the building to come and fix some of the sash windows as not all open. However each room does have one sash window that will open. The home is also investigating ways that people who The Priory DS0000064595.V359663.R01.S.doc Version 5.2 Page 18 use the service can access the gardens at the back due to steepness of the steps and pathway down. People spoken with said they were very pleased with their rooms and felt the environment was very pleasant. The views from several rooms of the local countryside were very pleasurable and some said how much they enjoy looking at them. During the tour of the bathrooms two were identified as having tiles that needed to be replaced. The Registered Manager said they are due to be repaired very shortly and they are aware of these issues. In several of the rooms used by people equipment had been provided to assist staff in caring for them and these included pressure relieving mattresses and profiling beds. Aids are provided around the home to include a shaft lift, stair lift, hoists and toilet frames. Protective clothing is provided for staff and situated around the home. Staff were seen wearing this when required. The laundry has been updated since the last inspection and it is much improved. New washing machines and dryers have been purchased. For infection control procedures linen trolleys are different colours so the staff know which is soiled linen. The homes AQAA states that domestic hours have been altered to suit the needs of people who use the service. During the tour of the home the standard of cleanliness observed was very good. In the surveys we received from people who use the service six people said the home is ‘always’ clean and fresh and 2 said ‘usually’. One person had commented, “bed linen is left in the main chair in their room”. The Priory DS0000064595.V359663.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained and have the skills needed to meet the needs of people who use the service. However staffing numbers are not always sufficient to enable this to take place. Unsafe recruitment practices potentially place people who use the service at risk. EVIDENCE: Copies of duty rotas were examined with the Registered Manager. The number of staff the home has on duty for each shift was discussed. This has changed since the last inspection as the home was aiming to have two qualified nurses on duty for a morning shift but at this inspection the home now has only one, however the Registered Manager did say sometimes they do have two qualified nurses on duty. The Registered Manager is extra to these numbers. Ancillary staff are available to support the care staff. As at the last inspection the Registered Manager said the dependency levels of people who use the service are monitored and staffing levels can be altered to ensure the needs of people are met. A number of the staff spoken with have been at the home for while and all staff said they enjoy working at the home. The home is using agency staff to cover some shifts. The Priory DS0000064595.V359663.R01.S.doc Version 5.2 Page 20 All people who use the service that were spoken with praised the staff saying they were wonderful and helpful. The comments we received from surveys include “there are less staff at the weekends I think”, “if the member of staff I want is not available there is always a stand in, this is a good example of how efficient they are” and “response time is sometimes slow through lack of staff”. People who use the service were asked in their surveys if the staff are available when you need them, two people said ‘always’ and five said ‘usually’. The homes AQAA states that they are just below the 50 of care staff trained in NVQ 2 in Health and Social Care, however six members of staff are undertaking this training and once completed the home will have met the recommended 50 . Personnel files of four new staff members that have started work at the home since the last inspection were examined; two had all the required checks in place. However one member of staff did not have a full employment history and another did not a POVAfirst check completed prior to them starting work at the home. Evidence was seen of POVAfirst checks and CRB’s for the three other staff. A CRB was obtained for the member of staff without a POVAfirst but this was received after they had started work at the home. Interview records were in place for each person. The recruitment practices seen at this inspection are unsafe and potentially place people who use the service at risk. The requirement for a full employment history and photograph is now outstanding for the last two inspections and must be addressed. The Registered Manager has devised a training matrix to record all the training undertaken by staff. Somerset Care has a training department within their company. The Registered Manager said that each month a different topic is covered. Records were seen of staff training and some staff do require some training, however the Registered Manager said this is in hand. Staff spoken with all confirmed that training is offered. Induction books were examined. The Registered Manager said the home is registered with Skills for Care. The home has two types of induction booklets depending if the staff member is a qualified nurse. The book is given to the staff member once they start working at the home. No staff were undertaking induction training at the time of the inspection but several certificates of completion of the induction programme were seen. The Priory DS0000064595.V359663.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A qualified and competent manager undertakes the management and administration of the home. Quality assurance systems are in place to make sure the home is run in the best interests of people who use the service. EVIDENCE: There have been no changes to the management of the home since the last inspection only that the Manager has been registered with us. She is a qualified nurse and is hoping to complete the Registered Managers award in the next few months. The Registered Manager also undertakes the same training as the other staff. The Priory DS0000064595.V359663.R01.S.doc Version 5.2 Page 22 Staff spoken to all said the Registered Manager is approachable she operates an ‘open door’ policy. The home has an unmet requirement that has now been outstanding for the last two inspections and must be addressed as a matter of urgency. Unsafe recruitment practices potentially place people who use the service at risk. Somerset Care has a number of quality assurance systems in place and the last full audit of the home took place in March 2008. Any areas that need improvement are identified. Regulation 26 visits take and records relating to these were examined. As part of the homes continued improvement they have plans to implement the ‘end of life training’. The home has four monthly friends and family meetings and for people who use the service. Minutes were seen of a selection of meetings. A monthly newsletter is sent out to people and quality assurance surveys were sent out about a month ago and the home is waiting for the results. The home has systems in place to manage people’s monies and records agreed with the monies kept. The home has a secure place to store this. Records of audits were seen and these take place at least twice a year. Staff supervision was discussed with the Registered Manager and randomly selected staff records relating to this were examined. The home is not quite meeting the recommended six times per year sessions for care staff, however the Registered Manager said they are looking to improve on this. The home also has staff meetings. A list of dates of servicing of equipment was included in the home Annual Quality Assurance Assessment. Maintenance records were seen in relation to health and safety checks undertaken by the home. Records relating to fire equipment checks were also seen along with the homes fire risk assessment. An evacuation procedure that includes information about how people can exit the building is yet to be put into place. The home has been awarded four stars in February this year from Environmental Health Department in relation to the kitchen. The Priory DS0000064595.V359663.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 The Priory DS0000064595.V359663.R01.S.doc Version 5.2 Page 24 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 OP2 Regulation 5 Requirement The home must make sure that their Service Users Guide provides people who use the service or may use the service with information in relation to; The arrangements in place for people to access additional services and how they would pay for them. And if this would be different if that person’s care was funded in whole or part by another party. The home must make sure that people who use the service receive information about how the home manages the Funded Nursing Care Contribution (FNC) payment if it is applicable to them or their representatives. The Registered Persons must ensure that recruitment checks required in Schedule 2 of the Care Homes Regulations are obtained prior to the staff member starting work. (This relates to a full employment history, together with a satisfactory written explanation of any gaps and a recent DS0000064595.V359663.R01.S.doc Timescale for action 01/08/08 2. OP2 5A & B 01/08/08 3. OP29 19 01/08/08 The Priory Version 5.2 Page 25 photograph). This requirement has been repeated from the last two inspections. 4. OP29 19 The home must make sure that 01/08/08 recruitment checks that are required are obtained prior to the member of staff commencing duties at the home. This will help to reduce any risks to people who use the service. This relates to: Two written references including where applicable a reference relating to the person’s last period of employment. A POVAfirst check (if applicable) and a Criminal Records Bureau Disclosure. 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 OP9 OP18 OP38 Good Practice Recommendations The home should review their homely remedy policy with the GP’s as it was last reviewed in October 2004. The home should consider sending staff on the ‘alerters’ guide training and the Registered Manager on the enhanced training provided by the local council. The home should complete their fire evacuation procedure that informs staff how people can exit the building in case of fire as a matter of urgency. The Priory DS0000064595.V359663.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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