Care Home: Primrose Lodge

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What the care home does well The staff give good care with dignity, privacy and relate well to the residents. `The staff are lovely` The residents have a clean and pleasant home to live in. The home gives the residents a good diet and they have choices in what they have to eat. ` The food is good and the staff look after me well` The manager and the staff welcome visitors into the home and communicate well with them. The home has a good recruitment practice, with all the required documentation in them. This makes sure that, as far as possible, the residents are safe. What has improved since the last inspection? The acting manager has made an application to become the Registered manager. The home is now sending the Commission for Social Care Inspection the notices required when an incident happens in the home. What the care home could do better: The Statement of Purpose should be produced to contain all the required information for people to be able to make an informed choice about the home. Consideration could be made to include the results of the annual quality audit into the Statement of Purpose to let people know what people who use the service think about it. The risk assessments could have better instructions on how to deal with an identified risk. The staff must have up to date instruction on how to move the residents safely. The home should have a list of the staffs` names together with their signatures and initials so that they can be identified when signing for medication. The manager should check the medication records and medicines monthly and document the results.The complaints policy could be made available in other formats to make sure that more people can read it. The complaints policy should be updated to include the details for Social Services and the new contact details for the Commission for Social Care Inspection. The lock on the front door must be repaired to make sure that the residents are kept safe from intruders. Consideration could be made to improve the application form for employment to include space for previous employment dates. CARE HOMES FOR OLDER PEOPLE Primrose Lodge Lingdale East Goscote Leicestershire LE7 3XW Lead Inspector Thea Richards Unannounced Inspection 23rd July 2008 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 Primrose Lodge DS0000001700.V369000.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. Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Primrose Lodge Address Lingdale East Goscote Leicestershire LE7 3XW 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) 0116 2697871 F/P 0116 2697871 Mr John William Nunn Mrs Barbara Elsie Nunn Ms Samantha Joanne Bacon Care Home 15 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (15), of places Physical disability over 65 years of age (4) Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No person of category DE(E) may be admitted to the home when 6 persons with dementia are currently residing at the home No person of category PD(E) to be admitted to the home when 4 persons with physical disability are currently residing at the home 23rd October 2007 Date of last inspection Brief Description of the Service: Primrose Lodge is a care home providing personal care and accommodation for 15 older people with a physical frailty and/or mental health needs. The home is part of the Broadoak group of homes owned by the Registered Providers Mr John William Nunn and Mrs Barbara Nunn. Mrs Mandy Kyle has been the acting manager for nearly two years and has now made an application to be the Registered manager. The home is situated close to the centre of the village of East Goscote and can be reached by private and public transport. There is visitors’ parking in the grounds. The accommodation is a purpose built single storey home with a lounge/ dining room and single bedrooms. The home is well maintained and provides a safe, comfortable and homely environment for the residents to live in. There is a small kitchen for the preparation of drinks and light snacks with main meals being cooked at Primrose Lodge’s sister home, Lingdale, which is directly opposite. Outside, there is a well - maintained patio and garden area with seating and flower beds, which is easily reached for the residents to use in the better weather. The current registration certificate from the Commission for Social Care Inspection is available in the reception area with an up to date insurance certificate. The latest report from the Commission for Social Care Inspection is available in the managers’ office. The home can be contacted by telephone or fax. Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 5 The current fee level is £ 460.00 There are extra charges for hairdressing, chiropody, newspapers and personal items. Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 2 Star. This means that the people who use this service experience good quality outcomes. This was a key inspection of a care home for older people, which ended with an unannounced visit to the service. Before the visit we (throughout the report the use of ‘we’ indicates the Commission for Social Care Inspection), spent four hours reviewing information received by the Commission for Social Care Inspection (CSCI) since the last inspection on the 23rd July 2008. The visit took place on the 23rd of July 2008 and lasted five hours. During the visit we checked all the ‘key’ standards as identified in the National Minimum Standards. This was achieved through a method called ‘case tracking’. Case tracking means that we looked at the care provided to three of the residents. To achieve this we spoke with the staff supporting their care and looked at the records relating to their health and welfare. We spoke with the residents and their families. With their permission the residents’ bedrooms were looked at. We also checked how the home was run and organised. This included looking at staff records, training and how the staff are organised. We looked at health and safety records, menus, minutes of meetings and the quality audit. The policy for handling complaints and how the home dealt with them was looked at. We looked at how prospective residents and their families are given information about the services the home can offer and whether they are suitable for them. We looked at the Annual Quality Assurance Audit (AQQA) that the home had sent to us. This describes the services provided at the home for the residents, how the home are hoping to improve services and statistics about the residents and the staff. During the visit we spoke with the person in charge, the manager from Lingdale, the residents, the staff and families and visitors to the home. What the service does well: Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 7 The staff give good care with dignity, privacy and relate well to the residents. ‘The staff are lovely’ The residents have a clean and pleasant home to live in. The home gives the residents a good diet and they have choices in what they have to eat. ‘ The food is good and the staff look after me well’ The manager and the staff welcome visitors into the home and communicate well with them. The home has a good recruitment practice, with all the required documentation in them. This makes sure that, as far as possible, the residents are safe. What has improved since the last inspection? What they could do better: The Statement of Purpose should be produced to contain all the required information for people to be able to make an informed choice about the home. Consideration could be made to include the results of the annual quality audit into the Statement of Purpose to let people know what people who use the service think about it. The risk assessments could have better instructions on how to deal with an identified risk. The staff must have up to date instruction on how to move the residents safely. The home should have a list of the staffs’ names together with their signatures and initials so that they can be identified when signing for medication. The manager should check the medication records and medicines monthly and document the results. Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 8 The complaints policy could be made available in other formats to make sure that more people can read it. The complaints policy should be updated to include the details for Social Services and the new contact details for the Commission for Social Care Inspection. The lock on the front door must be repaired to make sure that the residents are kept safe from intruders. Consideration could be made to improve the application form for employment to include space for previous employment dates. 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. Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 9 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 Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 10 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): 1, 2, 3. 6 is not applicable in this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ needs are always assessed before moving into the home and they have some information to help them make a choice about the home. EVIDENCE: All of the residents who were ‘case tracked’ had been given a Statement of Purpose and terms and conditions. The Service Users’ Guide gives people some of the information that they need to know about to help them make a decision about the home. The Statement of Purpose should be updated to include the information required by the national minimum standards. The new address and telephone number for the Commission for Social Care Inspection should also be included. Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 11 Consideration should be made to include the results of the homes’ annual quality audit. Providing a comprehensive Statement of Purpose & Service Users’ Guide makes sure that the residents have good information, so that they can choose the most suitable care. The acting manager or a senior member of staff always visits prospective residents before they are admitted to the home and there is a good pre admission assessment form in place. This was seen in the care plans looked at and we were told that ‘The manager visited me in the hospital’ It was also confirmed by the other residents and the families spoken with. This makes sure that that the manager and the staff in the home have the the right information before the resident is admitted, so that they can get the best care. It makes sure that the home can meet the residents needs and that the resident meets someone from the home who they can recognise. This makes the move into care easier to manage for them. The residents are given a months’ trial to see if they like the home and that it meets their needs before they make a final decision about staying. The families spoken confirmed that they were given the opportunity to visit the home before their relative came in. Members of the staff spoken with said that they always knew what the residents’ needs were before they moved in. The current registration certificate from the Commission for Social Care Inspection (CSCI) was displayed in the entrance of the home with an up to date insurance certificate. A copy of the latest report from the CSCI was available in the acting managers’ office. Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 12 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff meet the care needs of the residents as identified in the care plans with privacy, dignity and respect. EVIDENCE: All of the ‘case tracked records were found to contain good individual evidence of the care being given to the residents and reflected the care that the residents needed. The residents and the families spoken with told us about the care that they needed and that they were happy that they received it. There are records of the involvement of G.P.s, district nurses, chiropodist, optician and dentist in them, showing that thorough health care is being provided for the residents. The residents and their families spoken with said that they could see the doctor Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 13 and other health professionals when they needed to. There was evidence that the care plans had been reviewed and the residents and the Families spoken with told us that they were aware of the care being reviewed. One of the care plans did not have a signature to say that they had agreed with the care to be given, but when spoken with they told us that they were happy with the care and didn’t wish to sign the care plan. Where this is the case, the decision should be documented in the care-plan. The daily record of care was up to date and the entries describe the residents day or activities fully, which makes sure that the residents receive the right care and the staff know what has happened to them during the day or night. We saw residents being treated with dignity and respect when staff spoke with them and undertook their care. The staff sat down with the residents and spoke directly to them. The staff seen giving care did so in the right way, giving the residents privacy where needed. Two residents were seen to be being moved inappropriately with an ‘underarm’ lift that could cause damage to the resident and/or the member of staff. There are records of what the resident has had to eat and to drink. This makes sure that the resident is having a good nutritional intake. There are records of the residents’ weight, which makes sure that they are not losing or gaining large amounts of weight. Staff spoken with were aware of the care needs of the residents and the residents and the families spoken with were happy that all care needs were being met. There were risk assessments in place to cover all the identified risks for the residents, however it was not always clear how the staff would manage the risk. The staff and the resident may be put at risk if the right instructions are not given, particularly for moving and handling risks. This makes sure that the residents and the staff are protected from any risks that have been identified, without restricting their activities. Medication records for the case tracked residents were in order. Medicines are given by the senior care staff who have had training to give medicines. We saw that the medicines were administered individually and the residents were seen to be taking them. The resident told that she was reassured that the staff gave her her medicines and that she got them on time. Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 14 The medicines are packaged by the chemist into a ‘monitored dosage system’ where each tablet is in a separate pop out card. The staff spoken with were knowledgeable about the medicines and where to obtain information. They were also aware of the requirements for the receipt, storage and disposal of medicines. The chemist completes regular checks to make sure that the homes’ medicines are correct and being administered correctly. The acting manager could complete a monthly written audit of the medicines and the medicine sheets to make sure that they are correct. The staff use initials when signing that they have given the medicines and the acting manager should make sure that she has a record of the staffs’ names, signatures and initials to make sure that they can be identified in the future. There is a self-medicating policy in place but there were no residents looking after their own medicines at that time. Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 15 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. Quality in this outcome group is good. This judgement is made using available evidence including a visit to the service. The residents have their social, spiritual and nutritional needs met. EVIDENCE: The T.V was on in the lounge during the whole visit, which the residents told us that they were enjoying. A member of staff was seen to be sitting with a resident helping her with her knitting. There was no formal activity happening on the day of the visit, although we were told that there were regular activities such as, bingo, quizzes, sing-alongs and exercise, classes. The staff, the residents and the families spoken with told us that they did have activities and that they were happy with the amount. There was evidence in the daily records and in the care plans about the activities that the residents take part in. Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 16 All the families spoken with said that they were made very welcome in the home, which we saw whilst we were there. The residents spoken with said that the food was good and that they had a choice of what they had. The menus were varied and were discussed with the residents at residents meetings. The meals are cooked at the homes’ ‘sister’ home in the grounds, they are transferred in a heated trolley and we saw them being served onto hot plates. Special diets can be catered for and a resident told us that ‘They take care of my diabetes’ We spent time talking with the residents at lunch- time. The meal looked plentiful, well presented and the residents were enjoying it. Comments made by the residents included: ‘ The food is good and the staff look after me well’ The religious needs of the residents are met with regular services held in the home or in the sister home that the residents can attend or with the clergy visiting the home to see individuals. Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 17 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, 17, 18. Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. There are systems in place to support and protect residents and staff are aware of the processes. EVIDENCE: There is a complaints policy in place which gives the details of how to complain and who to complain to in the home if they needed to. The details for Social Services are not in the policy and the details for the Commission for Social Care Inspection are out of date. This could be made available in a large print, which would make sure that as many people as possible can read it. The home had received no complaints since the last inspection on 23rd October 2007. The Commission for Social Care Inspection has not received any complaints in this time. The residents and the families spoken with were aware of the policy, of how to complain and who to complain to. They were happy that their concerns would be listened to and acted on. The staff spoken with were aware of how to handle any complaints. The staff spoken with were able to describe how they would deal with an allegation of abuse, knew the areas where abuse could happen and could describe the process that they would go through if they suspected any abuse. Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 18 They confirmed that they had had training in safeguarding adults and whistleblowing and the person in charge and the records seen supported this. Most of the staff have either got an NVQ at level 2 or have started the award, during which they receive training in safeguarding. They were confident that the management would handle any issues correctly. We saw the accident book, which had been completed correctly. These practices make sure that the residents are safe from any abuse and that any concerns are handled correctly. Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 19 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, 23, 24, 26. Quality in this outcome group is good This judgement has been made using available evidence including a visit to the service. The residents are protected by the policies and procedures in the home to provide a safe environment. EVIDENCE: Primrose Lodge is a purpose built single storey home that is on the same site as its sister home Lingdale Lodge in the Leicestershire village of East Goscote. The home was unlocked on our arrival and the person in charge told us that the lock was broken on the door. The maintenance person was contacted during our visit to repair it. There was a bolt on it that was used at night. The only smoking area for the residents in the home is in the lobby in front of the front door that people have to go through to enter the home. Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 20 The home was clean and welcoming on our arrival. There is a large lounge/dining room that is a clean and bright place to sit. The bedrooms that were seen had been personalised and were found to be clean and well decorated and each had en-suite facilities. The residents spoken with were happy with their rooms and said that they were able to bring their own belongings in with them. The bathrooms were clean and clear of any items that could cause a hazard for the residents. There is a pleasant garden area outside with a small patio area that is accessible for the residents to sit in. The residents and the families spoken with were happy with the cleanliness of the home. The home employs dedicated staff to do the cleaning in the home and they have had training in health and safety. The cleaning products are stored in a locked cupboard. This was seen by us and confirmed by the staff spoken with. The meals are prepared at Lingdale Lodge, but there is a kitchen that is used for preparing snacks and drinks. The water temperatures and the fire alarms had been tested recently and were found to be within the required limits. The fire drills were up to date and the staff spoken with confirmed that they had regular fire drills. Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 21 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. Quality in this outcome group is good. This judgement is made using the available evidence including a visit to the service. The residents’ needs are met and the recruitment policy and the training protect their safety. EVIDENCE: The duty rota reflected the number of staff on duty on the day of the visit and all the shifts covered by the four weeks seen. The residents, staff and families spoken with felt that there were enough numbers of staff on duty to look after their needs. We looked at two staff files and the required information was complete in all them. This included evidence of identification, adequately completed application forms, two written references, a Criminal Records Bureau (CRB) check and a Protection of Vulnerable Adults check. The application form did not have enough space on it to give details of previous employment. This is necessary to make sure that prospective staff have the right experience and that any reasons for gaps in employment can be explained. Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 22 The management makes sure that all the required documentation is in place before an employee starts work. This was confirmed by the staff spoken with who told us that they could not start until they had all the paperwork in place. There was evidence of staff training including induction and the staff spoken with confirmed that they had received recent training in moving and handling, medication and safeguarding. The residents and the families spoken with felt that the staff were well trained to do their job. All of the staff either hold a National Vocational Qualification (NVQ) at least at level 2 or are in the process of completing it. The National Vocational Qualification is a qualification for care staff to make sure that they receive training in the needs of the resident group whom they are caring for. Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 23 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. Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. The residents benefit from management that is committed to their safety, care and needs. EVIDENCE: The acting manager was on annual leave during the visit, but there was senior carer in charge who was able to find what we needed. The manager from Lingdale Lodge came over during the visit to make sure that we had all we needed. The acting manager has made an application to the Commission for Social Care Inspection to be the registered manager. Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 24 The residents are seen regularly on an individual basis as are the families and discussions are held on how the home is meeting their needs. There is an annual quality questionnaire sent to the residents and their families, the residents, their families and the questionnaires that we saw on the visit confirmed this. We received positive comments from the residents and the families amongst which were that there was good communication with the home and that the staff were very supportive of them and their relative. The residents’ accounts were seen and all in order with two signatures on entries and receipts obtained for purchases. There was evidence in the records and from staff spoken with that formal staff supervision is taking place at the required frequency. Formal supervision of the staff gives them and their ‘line manager’ the opportunity to discuss work and training issues and needs. There are regular staff meetings held, confirmed by records held and by the staff. Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 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 2 17 X 18 3 1 X X X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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. 2. Standard OP7 OP19 Regulation 13 (5) 13 (4) (c) Requirement The staff must receive instruction in the correct method of moving the residents. The lock on the front door must be repaired. Timescale for action 30/08/08 24/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The Statement of Purpose should be produced with the information required in schedule 1 of the national minimum standards. The Statement of Purpose could include the results of the annual quality audit. The risk assessments should have clear guidance on how to deal with an identified risk. The manager should regularly audit the medicines and the MAR sheets and record this information. (This recommendation was made in the last report) 2. 4. 5. OP1 OP7 OP9 Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 27 6. 7. OP9 OP16 8. 9. OP16 OP29 There should be a signature sheet to identify the care staffs’ signature and initials. The complaints policy should be able to be produced in other formats to allow a wide range of people to be able to read it. (This recommendation was made at the last inspection) The complaints policy should be updated to include the address for Social Services and the new contact details for the Commission for Social Care Inspection. The application form should be redesigned to allow enough space for the dates of previous employment to be included. Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. Extracts may not be used or reproduced without the express permission of CSCI Primrose Lodge DS0000001700.V369000.R01.S.doc Version 5.2 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. 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