Care Home: Priory Care Home, The

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What the care home does well Information is available about the service, and what can be provided to help people and their families making decisions about their future care needs. Opportunities for introductory visits and short stays are provided to help with these decisions. People say they are happy living at the home. People are given help and support to make choices in their daily lives and say they are treated with dignity and respect at all times. A variety of activities are provided and people can choose to take part if they want to. The Priory provides opportunities and support for people to maintain their interests and any hobbies they may have. The Priory looks after people well and writes down what help everyone needs. People are supported in their medical appointments, and staff work well with other professionals and agencies to maintain the wellbeing for everyone living at The Priory. Staff are trained to help them understand how to meet people`s needs and give them the support they want. The Priory makes sure that suitable staff are employed and that all checks are made to keep people safe. The management team supports staff working at The Priory.People are supported to keep in touch with their families and friends. Visitors are made welcome and the atmosphere in the home is relaxed and friendly. People can choose what they want to eat from the healthy and nutritious menu. Alternative options to the main menu are always provided, and snacks and drinks are available at all times. What has improved since the last inspection? The Priory has responded to the requirements and recommendations made at the last inspection. Procedures have been reviewed and care plans have been developed to promote a more person centred approach to care. The statement of purpose and service user guide has been updated and now has more specific information about the facilities provided in the home. The storage of medication has improved and procedures have been developed to make sure that people who use the service are fully protected. People are encouraged to make choices about their activities and daily living. Varied activities are offered to help people maintain their interests and learn about new ones. Contact details have been added to the complaints procedure to help people should they wish to make a complaint. Staffing levels and rotas have improved. The rotas clearly identify all staff on duty and those staff due to work. Staff training is improving and more staff are achieving qualifications. The refurbishment and redecoration of areas within the home has enhanced the environment. There are continuing plans for further work to be carried out. What the care home could do better: An action plan should be developed to make arrangements in the event of a temporary closure of the home as a consequence of a disaster such as a flood or fire. The acting manager should make an application to CSCI for registration. Develop the quality assurance and monitoring system to help produce the best outcomes for people who use the service, and to measure how well the aims and objectives of the service are being met. CARE HOMES FOR OLDER PEOPLE Priory Care Home, The Crutch Lane Dodderhill Droitwich Spa Worcestershire WR9 8LW Lead Inspector Dianne Thompson Unannounced Inspection 09:30 21 February 2008 st 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 Priory Care Home, The DS0000063578.V359744.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. Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Priory Care Home, The Address Crutch Lane Dodderhill Droitwich Spa Worcestershire WR9 8LW 01905 771595 01905 796038 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) Daniel Timothy Johnson Mrs Sara Naomi Bate, Adam David Johnson Care Home 30 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (30), of places Physical disability over 65 years of age (30) Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2007 Brief Description of the Service: The Priory is a large, detached property, formerly a Vicarage, which has been adapted for its present use as a care home. The home is situated in a quiet, rural area on the outskirts of Droitwich. There is a large car park at the front of the premises and a large garden at the rear. The home is registered to provide personal care for a maximum of 30 service users over the age of 65 years. People who use the service are accommodated in single bedrooms on the ground and first floor. Twenty-two of the bedrooms have an en suite facility. A number of the bedrooms enjoy attractive views of the surrounding countryside and the adjacent golf course. There is a passenger lift and a stair lift to enable people to access the accommodation on the first floor more easily. There are two lounges and a conservatory and a separate dining room. The purpose of the service is to provide an environment in which older people may lead as normal a life as they are able. The underlying philosophy of the service is to ensure that care, well-being and comfort are of prime importance and to support people to maintain their dignity, individuality and privacy. Priory Care Home, The DS0000063578.V359744.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 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection visit to see what the home was like for the people who live there. Time was spent talking to some of the people who live at The Priory and some of the staff working there. We looked at some of the policies and procedures in the office with the acting manager. We sent out surveys to get views about the service from other people. The acting manager and the Responsible Individual completed an Annual Quality Assurance Assessment (AQAA) and sent this to the Commission for Social Care Inspection (CSCI). A tour of the premises was also made. Information gathered from other sources, such as monthly visit reports and notifications sent to the CSCI, has been included in this report. What the service does well: Information is available about the service, and what can be provided to help people and their families making decisions about their future care needs. Opportunities for introductory visits and short stays are provided to help with these decisions. People say they are happy living at the home. People are given help and support to make choices in their daily lives and say they are treated with dignity and respect at all times. A variety of activities are provided and people can choose to take part if they want to. The Priory provides opportunities and support for people to maintain their interests and any hobbies they may have. The Priory looks after people well and writes down what help everyone needs. People are supported in their medical appointments, and staff work well with other professionals and agencies to maintain the wellbeing for everyone living at The Priory. Staff are trained to help them understand how to meet people’s needs and give them the support they want. The Priory makes sure that suitable staff are employed and that all checks are made to keep people safe. The management team supports staff working at The Priory. Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 Page 6 People are supported to keep in touch with their families and friends. Visitors are made welcome and the atmosphere in the home is relaxed and friendly. People can choose what they want to eat from the healthy and nutritious menu. Alternative options to the main menu are always provided, and snacks and drinks are available at all times. What has improved since the last inspection? What they could do better: An action plan should be developed to make arrangements in the event of a temporary closure of the home as a consequence of a disaster such as a flood or fire. The acting manager should make an application to CSCI for registration. Develop the quality assurance and monitoring system to help produce the best outcomes for people who use the service, and to measure how well the aims and objectives of the service are being met. Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 Page 7 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. Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 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 Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information is available about the service, and what can be provided to help people and their families making decisions about their future care needs. People are given opportunities to visit and assessments are completed before people move in to make sure their individual needs can be met. EVIDENCE: The Priory has policies and procedures in place for assessing potential people to live at the home. Information about the home included in a Statement of Purpose and Service User guide is available and provided for all enquirers and residents. A log is maintained to record where copies have been issued. An updated copy of the Statement of Purpose and the Service User Guide was provided during the inspection visit that reflected the changes to the management of The Priory and up to date details for the Commission of Social Care Inspection. This information is now more specific about what facilities are Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 Page 10 provided within the home. An action plan should be developed to make arrangements in the event of a temporary closure of the home as a consequence of a disaster such as a flood or fire. Evidence was seen to show that full Community Care Assessments have been received and in addition The Priory complete their own assessments. Care plans are written from the information gathered during assessments, visits and discussions with families and other interested parties. It is stated in the AQAA that ‘we involve relatives and friends in supporting service users whilst enabling them personally to make an informed choice about the home. Visits are encouraged and arranged in order that prospective service users may flavour the atmosphere maybe enjoy a meal and view the facilities of the home, including consultation and experiences of those already living in the home’. The statement of terms and conditions of residence (contract) has been amended so that it includes the name of the home and the specific room to be occupied. A recent admission to The Priory confirmed introductory visits had taken place and that information about the home had been provided before a decision was made to move to The Priory. It was confirmed that a contract has been given that identified the room she was to occupy. Although the move had been an emotional one she said that ‘staff had been supportive and helpful’. Surveys confirmed that information about the home is shared, and that people are kept up to date with important issues. Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 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. 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. Individual health and personal care needs are being well met by the staff at The Priory. Care plans are completed and reviewed regularly. This makes sure that staff have all the information they need to provide consistent support. Risk assessments show how risks are to be reduced and how independence is promoted and maintained. The Priory has a medication policy and procedure for staff to follow to ensure that all medication is administered and stored safely for the protection of everyone who uses the service. EVIDENCE: Care plans for four people were viewed and all contained appropriate information about their needs and how they were to be met. The plans for each person are based on initial assessments completed before being admitted to The Priory. Information provided in these care plans cover all aspects of each person including their daily living needs, health and personal care, Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 Page 12 physical well-being, social interests and relationships, religious and cultural needs and any other specific areas. The care plans set out in detail the action that needs to be taken by care staff to make sure that all needs are met. The Priory is developing a more person centred system (PCP) for the service and their recording system is being developed to emphasise this approach. People living at the home confirmed that they are involved in their care planning and that their care needs are discussed with them and their family. Staff said they are fully aware of the plans and follow them to guide their practice. Each person is allocated a key worker to oversee his or her care. This allows staff to work on a one-to-one basis and contribute to the care planning for each person. It is stated in the AQAA that ‘We have in place individual working care plans for each service user, reviewed involving the person and if agreed their representatives’. Risk assessments are completed to keep people safe, with suitable guidelines for assistance as necessary. This includes mobility, moving and handling, and nutritional needs. Dementia reviews are conducted regularly to assess the level of dependency for each person. Completed risk assessments identify dates for planned reviews and explore ways to make sure that people are able to be as independent as possible. A relative’s view of the care and support provided at The Priory is that their mother ‘is well cared for and is very happy’. Other surveys confirmed that care given is what they expected or agreed with the service. Comments include ‘the staff are good and always approachable’ and ‘always give good care’. People have good access to medical support through their Primary Health Care team as required. Where possible people are supported to attend local medical appointments, with home visits arranged for people unable to leave the home. A record of visits to the home by doctors or other medical professionals is maintained. There is evidence to show where professional consultation has taken place, for example in relation to the use of over the counter medicines. Surveys were sent to medical professionals and confirmed that staff liaise with the medical practice, that meetings are held in private, and there have been no complaints about the service. Other comments included a ‘positive approach to the care of the residents at the home’ and ‘Caring staff.’ Staff were observed providing support for people in a respectful way, making sure that each persons’ dignity and self esteem was important. There is a separate lounge area and a medical room for meetings if people do not wish to take visitors to their bedrooms. People appeared to be comfortable and at ease in their surroundings. People living at The Priory said they found staff ‘helpful’, ‘caring’ and ‘they treat me as a person in my own right’. Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 Page 13 The administration and storage of medication has improved following the previous inspection and is now being well managed by the staff at The Priory. Medication is stored securely and given to people at the right time and full records are kept which show this. The refrigerator used for storing medication that requires cold storage is now kept locked at all times when not in use. The supplying pharmacist recently audited the storage and administration of medication at The Priory. A policy and procedure is in place for the administration of medication and this has been amended to reflect good practice particularly in regard to the administration of medication during the night. The acting manager provided evidence to show that the policy and procedure is now reviewed at least once a year and is signed and dated. The acting manager said that accredited training has been provided for staff on the administration of medication, and that staff have recently completed specific training on Dementia Care. Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive help and encouragement to make choices and decisions about their lives. Everyone is encouraged and supported to maintain links with their families and to develop friendships. Dietary needs are well catered for with a varied and healthy menu provided. EVIDENCE: People living at The Priory are encouraged and supported to make choices about activities and daily living with as much control over their lives as they are able. People are able to make a choice about how to spend their day. One person said that ‘staff do try and encourage me to join in, but I don’t always want to. I like to spend time on my own, but they still ask me and give me the choice’. Various recreational activities are offered to help people maintain their interests. Evidence was seen in care plans to show daily routines and support given for specific interests, such as regular outings each month to local clubs where people are members. Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 Page 15 Activities are recorded in each persons care plan. There is evidence to show that the range and frequency of activities has improved since the last inspection. Activities on offer include movement to music, a fashion parade, playing board games, sing along, bingo, hairdressing and skittles. Occasional trips are arranged from time to time and seasonal celebrations are also organised. Notices are posted onto the communal notice board and individual invites are given to all residents to inform them of activities on offer. The Priory has a large garden and people are encouraged to spend time there, particularly in the summer. Regular residents meetings are held, and at a previous meeting it was decided that pots and bedding facilities on the veranda to the rear of the property would enable residents to tend their own tubs and grow their own plants, such as tomatoes. Surveys from families said they were ‘satisfied with everything’ although one person commented they would ‘like more outings to be arranged’. The spiritual needs of people who live in the home are well supported and visits by various organisations are facilitated. Members of the local chapel visit the home each month to sing and talk to people. On average, members of the Salvation Army visit the home three times a year. Visits take place every month from the Anglican Minister, and a member of the Catholic Church visits each week. Evidence shows that regular contact with friends and family is supported. People who use the service confirmed that they are able to see their visitors in private, and that their visitors are made welcome and offered a drink. Survey responses show that families visit their relative at the home on a regular basis and that they are ‘always made to feel welcome’. Records show that varied and nutritional meals are provided and alternative meals where these have been chosen. People are offered three full meals each day, with snacks and drinks available throughout the day. Details of the daily menu are displayed in the notice board in the main corridor by the dining room. People are consulted about their choice of food and diets. Food samples are now kept for a period of 72 hours in case there is an outbreak of food poisoning. People who use the service said they ‘liked the food’, and thought the ‘choices are very good’. Survey comments included that people ‘eat very well at the home’ and ‘the food always looked appetising’. It is stated in the AQAA that ‘we have been awarded a good 4 star rating for the kitchens from Wychavon district council (Environmental health and commercial services dept) in January 2008. We have extended the kitchen to double in size and include a storage area. The kitchen has been completely refurbished with all new kitchen equipment supplied’. Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People have access to easy to understand information about how to complain and staff support people to express their views and any concerns they may have. There are suitable procedures in place for the management of complaints. There are suitable policies and procedures in place to make sure that people who use the service are protected from abuse. EVIDENCE: The Priory has a complaints policy and procedure in place which is accessible to people who live at the home and their relatives. Staff support people who live at The Priory should they wish to make a complaint. Survey responses show that people are aware of the complaints procedure and that no complaints have been made. One person explained that ‘I know who to talk to if I need to, but I don’t have any complaints’. The complaints log was seen and the acting manager confirmed that no complaints have been made to the service. The CSCI has not received any complaints about the home. Procedures are in place that guide responses to any allegations of abuse and in managing any complaints made about the service provided. Staff receive training in abuse awareness. A recommendation that the home’s policies and procedures on the protection of vulnerable adults from abuse should be reviewed at least annually has been completed. The Responsible Individual Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 Page 17 states in the AQAA that ‘We have improved the adult protection procedures available for the staff to include contact names and clear avenues to local authority departments. We have added contact names to the service users guide’. Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who live at The Priory enjoy a comfortable and homely living environment. The home is spacious and is kept clean and well maintained. EVIDENCE: A tour of the home was conducted. The Priory is a large, detached property, formerly a Vicarage, which has been adapted for its present use as a care home. The home is situated in a quiet, rural area on the outskirts of Droitwich. There is a large car park at the front of the premises and a large garden at the rear. There are pleasant views over the surrounding countryside. The property is accessible, comfortable, generally well maintained and provides a homely environment for the people who live there. The Priory is registered to provide personal care for a maximum of 30 service users over the age of 65 years. People who use the service are accommodated Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 Page 19 in single bedrooms on the ground and first floor. Twenty-two of the bedrooms have an en suite facility. A number of the bedrooms enjoy attractive views of the surrounding countryside and the adjacent golf course. There is a passenger lift and a stair lift to enable people to access the accommodation on the first floor more easily. There are two lounges and a conservatory and a separate dining room. The rooms seen were furnished and decorated to a high standard and had also been personalised by the people who live there. People spoken to said they ‘liked their room’ and ‘liked the view from their windows’. One person said it was ‘like living in a hotel with all clean linen and clothes’. The home is clean and tidy throughout. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. All cleaning materials are locked in the laundry room. Staff were observed wearing suitable protective clothing for the work they were doing, and confirmed that they were familiar with the procedures regarding the control of infection, and that they had been given training in health and safety matters. A written assessment of all the hazardous substances used by the home has been carried out in accordance with the recommendation of the Environmental Health Officer. A new infection control system ‘essential steps’ has been introduced into the service. Refurbishment to areas of the home has taken place since the previous inspection. The AQAA states that ‘we have completely refurbished the residents dining room to include all new décor, carpeting, tables and chairs. We have fitted double doors to the dining room to facilitate resident’s access at meal times. We have decorated six bedrooms including new carpeting and furniture. We plan to progress with the internal refurbishment program to include corridors, lounges and bedrooms’. There is a large garden to the rear of the property. Raised borders have been added to the garden and these are planted on a seasonal basis. An application for funding for a greenhouse has been made. Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are sufficient staff on duty with the right skills and knowledge to meet the needs of people who live at The Priory. Staff are well supported and work together to provide consistent and good quality care. Staff receive relevant training to help them meet the needs of people who use the service. Recruitment policy and practices make sure that suitable staff are employed. All necessary checks are made to ensure the safety of everyone living at The Priory. EVIDENCE: The Priory has a committed and stable staff team. Agency staff are employed if necessary, but the acting manager said they use the same agency to maintain continuity of care. The acting manager said the staff team are very well motivated and actively seek ways to improve the lives of the people who use the service. The staff rotas were seen and confirm that additional staff are now on duty at peak times of activity during the day. Staffing levels now consist of one senior care assistant and three care assistants during peak hours of the day. At the time of the inspection three care assistants and one senior were on duty, and people who use the service confirmed this. There are two members of staff Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 Page 21 on duty at all times during the night. The Priory employs two cooks and two members of staff to carry out domestic duties. Surveys confirmed that staff attitude is ‘perfect’. People who use the service commented that they were generally satisfied with the home, the staff and the food provided. The Priory operates a recruitment policy and procedure to ensure that everyone completes an appropriate application form and that suitable references are obtained including one from their most recent employer. Appropriate criminal records and other checks are undertaken before appointments are confirmed. All staff are required to work a probationary period at the home. Recruitment records were seen for three members of staff. The records are well-maintained and contained copies of all required information and safety checks. Each file has a staff checklist to ensure all checks are completed. Copies of references were seen. Regular staff training is provided. Staff complete mandatory training such as Health and Safety, Fire Safety, First Aid, Food Hygiene, Moving and Handling, Infection Control and Vulnerable Adults. Staff said that the training provided is ‘very good’. A record is maintained for all training undertaken at the home. The acting manager said that the training matrix is currently being updated to reflect recently completed training such as Dementia Care. The Priory provides a three-day staff induction programme. This is followed by the ‘Skills for Care’ Induction. Each new member of staff is issued with an employees’ handbook, which refers to principles of care such as respect, dignity, choice and individuality. Arrangements have been made for staff to receive training that will enable a minimum of 50 of the care staff to attain a qualification at NVQ level 2 or equivalent. The AQAA states that ‘we have stabilised the staff rota that is now consistent and efficient in numbers. We have increased the number of qualified staff up to 55 . We have engaged all other care staff in working to obtain an NVQ qualification’. All staff will complete their NVQ training and the acting manager said ‘it is anticipated that three more staff will have achieved their NVQ by the middle of this year’. Staff spoken to said they ‘enjoy their work’ and were very positive about their employment at the home. They appeared to be enthusiastic and well motivated, and confirmed that training is provided for them. They are also given the opportunity to share their views and opinions at staff meetings, and feel that they are listened to. Comments include ‘I wouldn’t be working here for all these years if I didn’t enjoy it’ and ‘we have a good staff team, ‘we all work well together sharing ideas and knowledge’, and ‘the organisation is very supportive’. Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well managed and staff receive the leadership and support they need. The Responsible Individual monitors the home in various ways to make sure that the health and welfare of people using the service is protected. EVIDENCE: The acting manager Penelope Lingard has many years experience working with older people, and previously worked for the Company at their sister home. Penny has worked as a training officer in more recent years, and is qualified to NVQ level 4, with additional teaching qualifications. Penny regularly completes training relevant to her position. Penny is to submit an application for position of registered manager with the CSCI. Three senior care staff support the Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 Page 23 acting manager and also provide an overnight on call service. Staff confirmed that the acting manager is approachable and supportive. One person said that ‘ the management are very hands on and help staff learn’. They also ‘provide the support’. People who use the service said that the manager was ‘very helpful’ and ‘always makes time to talk’. The Annual Quality Assurance Assessment (AQAA) was completed and submitted to the CSCI following the inspection visit. The need for a formal system for measuring how well The Priory succeeds in delivering a quality service where the results are audited and published annually were discussed. Evidence of progress was seen, but there is a concern about the length of time the recently introduced auditing system will take to complete. This is likely to make some of the information that has been gathered, as in survey responses, out of date by the time the audit has been completed. The service should consider how the quality assurance audit can be completed within an annual quality review so that results are determined and published. It is stated in the AQAA that ‘we plan to continue to engage with residents, relatives and stakeholders with various methods in order to run the home for the best interests of the residents. We plan to continue with the quality assurance program. We plan to seek registration of the acting home manager’. Records show that monthly checks of the fire safety system and equipment, water temperature and storage, fridge, freezers and electrical appliances are completed. Staff are undertaking all mandatory health and safety training topics. Generic risk assessments are in place. The fire risk assessment has been reviewed with annual reviews planned. A record of the monthly emergency lighting checks is now maintained in accordance with the recommendations of the Fire Safety Officer. A member of staff is now the designated fire warden and has the responsibility for fire monitoring, staff training, and fire risk assessments. The acting manager has introduced a system to ensure that the security of the premises is being maintained to a satisfactory standard. A checklist is now completed every evening to make sure all doors and windows are locked at night, that the building is secured and people are kept safe. Staff on duty at the time of the inspection confirmed this. The management of the home confirmed that staff do not have any involvement in the financial affairs of people living at The Priory. The acting manager said that the money and accounts for people living at the home are now independently audited every three months with an accurate record maintained of any items handed over for safekeeping. Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 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 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 OP2 Good Practice Recommendations An action plan should be developed to make arrangements in the event of a temporary closure of the home as a consequence of a disaster such as a flood or fire. The service is advised to consider ways in which the quality assurance audit can be completed within an annual quality review so that results are determined and published. 2. OP33 Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Priory Care Home, The DS0000063578.V359744.R01.S.doc Version 5.2 Page 27 - 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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