Inspection on 02/05/06 for The Priory [Tetbury]

This inspection was carried out on 2nd May 2006.

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

The inspector 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] 17/04/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Priory The Chipping Tetbury Glos GL8 8ET Lead Inspector Sharon Hayward-Wright Unannounced Inspection 10:00 2 and 3rd May 2006 nd 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.V290199.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 DS0000064595.V290199.R01.S.doc Version 5.1 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 Somerset Care Limited To be appointed Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Manager is to complete NVQ level 4 Registered Managers Award by 30 September 2006 31st October 2005 Date of last inspection 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 residents 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 £463.75 to £700 per week. The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out this inspection over two days in May 2006. 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 Manager and the Area Manager were available during the inspection as were other members of the home team. A total of 27 standards were inspected which included the following areas: • The homes process of pre admission assessment and ongoing assessment processes • Care planning, general care documentation and involvement of outside health professionals • How the staff maintain residents privacy and dignity • Residents ability to make choices • Family and friends visiting • Food and dining environment and related records • Complaint processes and related records • How the home protect the residents against harm and abuse • The cleanliness of the home and general infection control practice • Staffing and related records • Staff training and development and related records • The management style and structure • Quality Assurance • Residents personal monies • Staff supervision and related records • General health and safety practice and related records Several residents were spoken with to ascertain their views on the care and services provided. Feedback cards were left at the home for relatives and service users. Two feedback cards were received, one from a service user and a relative. The relative has requested new beakers as the old ones are stained. The Manager said the home is in the process of changing all its crockery and new beakers are included. One Social Worker was at the home undertaking reviews during the inspection and their views were sought. The comments received from service users all indicated they are very happy living at the home and the comments received from the Social Worker were all positive. This was the new Managers first inspection in charge of the home as at the last inspection she had only been at the home three days. All comments received about the Manager were very positive stating that she is friendly, approachable The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 6 and staff, service users and their relatives can talk to her about any concerns they might have. The Manager and Area Manager and care staff were spoken with throughout the inspection and were helpful and co-operative. Feedback on the inspection findings was given on completion and was received in a constructive and positive way by the Manager and Area Manager. One requirement had not been complied with since the last inspection. On this occasion the timescale has been extended as indicated in the requirements made. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescale may lead the Commission for Social Care Inspection considering enforcement action to secure compliance. What the service does well: What has improved since the last inspection? The home has improved their care plans by adding plans for each identified problem as they were missing from some of the care files inspected at the last The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 7 inspection. This will ensure that staff have the information needed to assist them in caring for the service users. The home has made improvements to their medication systems by making sure the Medication Administration Records contains instructions for the staff on how and when to give the medication instead of having ‘as directed’. A statement has been devised to provide service users and their family/representative with a breakdown of fees to show the amount of nursing contribution received. 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 DS0000064595.V290199.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. A statement has been devised by the home to provide service users and their family/representatives with a breakdown of fees where a nursing contribution is received. The home’s admission procedure ensures that all service users are admitted to the home on the basis of a full assessment of their needs, ensuring the home is able to meet the needs of the service user. Prospective service users and their family/representatives have the opportunity to visit the home and assess it for its suitability prior to the service user moving in. EVIDENCE: At the last inspection a requirement was issued for the home to provide service users in receipt of nursing care, who are receiving a contribution towards that The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 10 care, a statement specifying the breakdown of fees. Somerset Care has addressed this requirement by devising a form. However at the moment Somerset Care are awaiting guidance from the Department of Health regarding the administration of these fees to service users. The care records relating to a recently admitted service user were examined. A full assessment of their needs was undertaken prior to admission and then again the day after admission. From this care plans were devised. The Manager said that if a service user is funded by Social Services, their assessment and care plans are used as part of the home’s assessment. This service user confirmed that his family had visited the home prior to them moving in and they had taken care of the arrangements for them. The service user said they are very happy living in the home. Intermediate care is not offered at The Priory. The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. There is a clear and consistent care planning system in place, which adequately provides staff with the information they need to satisfactorily meet service users’ health and personal needs. Service users have access to health professionals when required. The systems for the management and administration of medications are good; with clear and comprehensive arrangements in place to ensure that service users’ medication needs are met. Personal support in this home is offered in such a way as to promote the service users’ privacy and dignity. EVIDENCE: Three-service users’ care was examined in detail by case tracking. From these three care files evidence was found that the requirement issued at the last inspection has been addressed. All had an assessment of needs completed on admission. However only two of these had assessments that were kept under The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 12 review. Regulation 14 states that service users assessment must be kept under review and any revisions made. The Manager said they would address this immediately and ensure all service users have an ongoing assessment of need. All service users had personalised care plans providing staff with information needed to care for the service users. Case tracking proved that the care provided to these three service users was current. Evidence was seen of monthly reviews of care plans. In the three care files examined in detail the home has completed a communication care plan documenting when the next of kin would like to be contacted and their numbers. The inspector felt this was an excellent idea especially in an emergency. Risk assessments were in place for nutrition, pressure sores, moving and handling and falls. One service user had an individual risk assessment, as they like to go out alone into the local town. One service user had wounds and there were records in place to monitor its progress. However the last full assessment of the wound on the home’s assessment chart was dated 9/3/06. It is recommended that this is updated more often. Another recommendation to monitor the progress of the wound is to use wound mapping or with the consent of the service user photographs. Evidence was seen of health professional visits to service users as these are recorded in their care files. Medication systems were inspected. Only qualified nurses administer medication and training in medication was undertaken in February this year. Records were seen of medication received, administered and where necessary returned to the local pharmacy. Records were also seen of controlled medication. All medication is stored in locked cupboards and at the last inspection a recommendation was made to fit another rag raw bolt through the back of controlled storage cupboard. The Manager said this has been looked at but they are unable to meet this recommendation, as the advice they have taken said this couldn’t be done. The home has good security arrangements in place. At this inspection all MAR sheets were examined and no ‘as directed’ instructions were found. Care plans contain information about how external medication should be applied and where to. Medication rounds were observed during the inspection and the home uses trolleys that are taken to the service user. 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. 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 service users can still receive this type of medication along with their prescribed medication. The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 13 One of the service users case tracked self-medicates. In their care file a risk assessment and consent form was seen. This service user said the staff order their supplies of medication when they get low. Staff were observed treating service users with respect for example knocking on their door prior to entering. Service users said the staff were wonderful to them and no concerns about the staff conduct were expressed to the inspector. The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected 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 excellent. This judgement has been made using available evidence including a visit to the home. A varied activities programme is available for service users should they wish to participate, otherwise they are free make their own arrangements. Service users are able to receive visitors at any reasonable time, as the home does not place restrictions on visiting. Dietary needs of service users are well catered for, with a balanced and varied selection of food available that meets service users’ tastes and choices. EVIDENCE: The home issues service users with a monthly newsletter detailing the activities happening that month. Copies of these were seen in the main reception area of the home. The activities coordinator maintains records of activities service users have undertaken. These include group activities, oneto-one and outings. Service users spoken with said they are able to choose whether they join in the activities provided. Feed back from a relative via a Social Worker said the activities have improved with more outings now being offered. One service user said they are able to go out into the local town alone and another service user was going out with a family member during the inspection. The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 15 Service users, a relative 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 will encourage service users where able to participate. Service users where able can make choices about their daily lives and information about advocacy services is available on the notice board outside the Managers office. Service users said they can choose how to spend their time each day and this includes where they want to eat their meals, as one service user said they prefer to eat their meals in their rooms. Service users’ personal possessions were seen in their rooms. The cook is in the process of reviewing the menus and is planning to make changes. They also have a list of service users’ likes and dislikes. The menus show that the home offers choices at each meal to service users and service users also confirmed this. The home is able to cater for service users who need special diets. A number of service users require liquidised meals and the cook said they are liquidised separately to enhance presentation. A mealtime was not observed at this inspection. Service users said how much they enjoy the food provided by the home. Drinks were seen being offered to service users at intervals during the day. Records of the food provided by the home are maintained, however further detail is needed in some of the recordings, for example type of sandwich fillings used, vegetables and the cakes offered to service users. See Standard 37. The kitchen was not inspected as maintenance work was taking place, however records were seen for cleaning schedules, food temperatures and fridge and freezer temperatures. The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be 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 the home. The home has a complaints system in place, however this has not been tested since the new Manager arrived at the home. Service users and relatives feel confident that their concerns will be listened to and acted upon. The home’s polices and procedures and staff’s knowledge of adult protection issues help to provide a safe environment for service users to live. EVIDENCE: From discussions with the Manager the home has not received any complaints since she has been running the home. A copy of the complaints procedure is on the notice board outside the Manager’s office. Consideration should be given to adding to this that service users funded by Social Services can also contact them. Service users spoken with said if they had any concerns they would approach the Manager, this was also confirmed by the Social Worker who was conducting reviews of service users during the inspection as she had also spoken to some families. The inspector also spoke to a relative who said she would also approach the Manager if she had any concerns. The Manager said that training in protection of vulnerable adults is planned and she will be teaching the staff using a training pack. Somerset Care is in the process of updating their policies and procedures at the moment. The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 17 One of the qualified nurses on duty was asked how they would deal with a situation if an allegation of abuse was made and the correct procedure was discussed. The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the home. The continued investment in this home has greatly improved the environment for service users by providing them with a comfortable and homely place to live in and for those visiting there. The home maintains good standards of cleanliness and there are appropriate systems in place for the control of infection. EVIDENCE: A tour of the premises took place and a number of service users’ rooms were seen. This is the first time the inspector visited the home and found the environment to be maintained to high standards and very pleasantly decorated. The Manager said that a number of areas have been redecorated and further plans are in place to continue this. The Manager discussed with the inspector that the home is looking to refurbish some of their bathrooms The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 19 that are not in use to ‘wet rooms’. The wet room they have is very popular with service users. Service users said they were very pleased with their rooms and felt the environment was very pleasant. The views from several service users’ rooms of the local countryside were very pleasurable and some said how much they enjoy looking at them. The home was found to have good standards of cleanliness on the day of the inspection and no odours were found. Service users and staff confirmed that this standard is always maintained. Staff were seen wearing protective clothing when required and on every floor there are areas where staff can access protective clothing and alcohol hand gel. The laundry assistant was spoken to who explained the procedure for managing soiled linen. This member of staff has received infection control training but she said it was a while ago. Consideration should be given to offering a refresher course. The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 20 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 adequate. This judgement has been made using available evidence including a visit to the home. The staff have a good understanding of service users’ needs and they work positively with service users to help improve their whole quality of life. Although the home has a robust vetting and recruitment procedure they must ensure the appropriate checks are completed prior to the staff member starting work at the home. The arrangements for the induction and training of staff are good, with the staff able to demonstrate a clear understanding of their roles. EVIDENCE: Copies of duty rotas were sent to the inspector with the pre-inspection questionnaire. These were discussed with the Manager. The home aims to have two qualified nurses on an early shift, one on a late shift and night shift. Five to six care staff are on an early and four on late shift and two on nights. The Manager is extra to these numbers. However on the first day of the inspection there was only one qualified nurse on an early shift and three care staff on a late shift. At the time of the inspection the home is under their registered numbers of service users. The inspector discussed with the Manager and the Area Manager about the concerns they had received from a number of staff in relation to the dependency levels of the service users. The Manager and Area Manager both felt that the staffing level were sufficient in The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 21 meeting the needs of the current service users. The inspector also explained that a relative and a service user said they felt the staff were always very busy. The Manager said the dependency levels of the service users are monitored and staffing levels have been altered to ensure the needs of service users are met. The home also has ancillary staff to undertake other tasks to support the care staff and these include cleaning, laundry and cooking. A number of the staff spoken with have been at the home for while and all staff said they enjoy working at the home. All service users and the relative spoken with praised the staff saying they were wonderful and helpful. The Manager has plans in place to meet the 50 care staff trained in NVQ 2 or equivalent, as the home is at present under the 50 . A member of staff is waiting to be trained as an assessor to help the staff complete their course. Personnel files of four new staff members were examined; one had all the required checks in place. However one did not have a full employment history, another did not have a photograph of the staff member and the last file had two references but not one from the last employer. The Manager said they are chasing this reference and had obtained a reference from their last care position. The Manager did obtain a full employment history and checked any gaps and the photograph; nevertheless these recruitment checks must be undertaken prior to the staff member starting work at the home. All had Criminal Records Bureau disclosures and POVA checks. Consideration should be given to storing these disclosures in a secure but separate file away from staff personnel files. The Manager is in the process of devising a training matrix to record all the training undertaken by staff. Somerset Care has a training department within their company and a full list of training offered was shown to the inspector. Records were seen of all mandatory training. Training for qualified staff in meeting their PREP requirements is also offered and the home has a notice board advertising training for staff. Staff spoken with all confirmed that training is offered. Induction books were examined. 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 and they are kept by the staff member to ensure they are completed with their supervisor. The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 22 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, 32, 33, 35, 36, 37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The Manager has a supportive, open approach to running the home, which benefits the service users, staff and relatives. The home regularly reviews aspects of it performance through a good programme of self-review and consultations which include seeking the views of relatives and staff. The home has plans in place to review the systems used for staff supervision; once in place the home will be able to ensure that staff will receive the appropriate supervision. The standard of record keeping is good, however further improvement is required in some areas. So far as is reasonably practicable the health, safety and welfare of service users, staff and visitors are promoted and protected. The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 23 EVIDENCE: The Manager has been at the home since last October and this is her first inspection in charge as she had only been at the home 3 days at the last inspection. She has applied to be considered for registration with the Commission for Social Care Inspection and an interview date has been booked. The Manager is a qualified nurse and has plans to start the Registered Managers award; confirmation of this will be needed for her interview. Staff spoken to all said the Manager is approachable and listens to any concerns they might have. They also said that she will do her best to resolve them. Staff said they are happy with the changes she has made so far and this has helped with their workload. Service users and a relative all said the Manager is approachable and they would also go to her if they had any concerns. The Manager said she operates an ‘open door’ policy and has a development plan in place. Somerset Care has a number of quality assurance systems in place. The home has four monthly friends and family meetings, service users meetings. Minutes were seen of both. Heads of departments meet weekly with the Manager as well as staff meetings. A service users’ survey was undertaken when the new Manager started and the on the whole the response was very positive. The home has a relative’s board for information and has ‘investors in people’ award. The Area Manager undertakes unannounced Regulation 26 visits and the inspector saw copies of these reports. The Manager has introduced a pressure sore audit and had plans to audit accidents. The home has systems in place to manage service users’ monies and records agreed with the monies kept. The home has a secure place to store service users monies. The Manager is not an appointee or agent for any service users. Information about service users subject to the Power of Attorney process was seen. The Manager has plans in place to review the supervision system used. The Manager wants the Named nurses to supervise their group of key workers. To do this the Manager is arranging training for the staff. This will be followed up at the next inspection. The records inspected were up to date and stored correctly except for the recommendation made about CRB disclosures and the food records need further detail as described in Standard 15. The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 24 A list of dates of servicing of equipment was sent to the inspector with the pre inspection questionnaire. Water temperature checks and Legionella testing were seen. The home is in the process of arranging an electrical wiring test. Somerset Care has plans in place to train their Managers ready for the new legislation in relation to fire. The home has a fire risk assessment in place. The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 2 2 3 The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 26 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 OP7 Regulation 14(2) Requirement The Registered Persons must ensure that service users assessment of need is kept under review and any revisions necessary are made. 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 photograph). This requirement has been repeated from the last inspection. The Registered Person must ensure that detailed records of food provided to service users are maintained. Timescale for action 25/06/06 2. OP29 19 25/06/06 3. OP37 Sch 4(13) 10/06/06 The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 27 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. 4. 5. Refer to Standard OP8 OP8 OP9 OP26 OP29 Good Practice Recommendations The home should complete its assessment of wound charts on a frequent basis depending on how often the wound is redressed. The home should use wound mapping and/or photographs with the consent of the service user to assist in the monitoring of the progress of wounds. The home should review their homely remedy policy with the GP’s as it was last reviewed in October 2004. The laundry assistant should receive an update on infection control. The home should store CRB/POVA disclosures in a secure place but stored away from individual staff files. The Priory DS0000064595.V290199.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 DS0000064595.V290199.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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