Inspection on 02/08/05 for Glebe Villa

This inspection was carried out on 2nd August 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Glebe Villa 24/06/08

Glebe Villa 22/06/07

Glebe Villa 09/06/06

Glebe Villa 27/01/06

Glebe Villa 26/01/05

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Glebe Villa 26 Glebe Road St George Bristol BS5 8JH Lead Inspector Sandra Jones Unannounced 2 & 4 August 2005 9:30 nd th 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Glebe Villa D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Glebe Villa Address 26 Glebe Road St George Bristol BS5 8JH 0117 954 1353 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Aston Care Homes Mrs Etylin Astbury Care Home 6 Category(ies) of LD Learning disability 6 registration, with number of places Glebe Villa D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 6 persons with learning disabilities aged 18 - 64 Date of last inspection 30/3/05 Brief Description of the Service: Gleve Villa is registered to provide accommodation and personal care to six adults with learning disabilities. It is located in the St George area of Bristol close to shops, amenities and bus routes. The property has the appearance of a domestic dwelling, blending well with its local residential environment. It is arranged over three floors with shared space on the ground floor and bedrooms on the first and second floor. An applicantion to extend the property has been receieved and its is the providers intention to increase the numbers from six to seven people and relocate the dining room and kitchen. Offering accommodation on the ground floor. Glebe Villa D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over two days on an unannounced basis. There were no additional visits to the home since the last inspection and the home are aware of their responsibilities on the requirements of Regulation 37. Four residents at home during the inspection agreed to give feedback on the standards of care at the home. The interactions between the staff and residents were observed and a close, friendly rapport was seen. What the service does well: What has improved since the last inspection? Since the last inspection the lounge and one bedroom was redecorated. Members of staff have attended training that ensures they have the skills and competences to meet the needs of the residents. Requirements made at the last inspection were actioned by the service provider. Glebe Villa D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Glebe Villa D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Glebe Villa D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 The Statement of Purpose and Service User Guide informs potential residents on the facilities and services to be provided. Additional information must be included in the Statement of Purpose for potential residents to make choices about the home. EVIDENCE: The up to date Statement of Purpose informs potential residents, their representatives and placing agencies of the facilities and services of the home. While the information about the staffing and organisational structure is comprehensive, the intended staffing ratio must be included. In terms of the admission process, the criteria for admission at the home must be incorporated. With the sizes of the rooms detailed, in the document. The Service User Guide combines as the Terms and Conditions of residency, it is helpful as it explains the services, expectations of both parties and rules of the home. There is additional space to include the name of the person, the allocated keyworker and fees. Glebe Villa D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 & 10 Care plans are up to date and guide the staff to meet the needs. A more person centred approach must be used to meet the person’s assessed need. The management of recorded information is consistent with the Confidentiality policy. EVIDENCE: Care plans are up to date and list the individuals assessed needs, with the actions to be taken to meet the need. It is clear that residents assessed needs in respect of physical, emotional, social and cognitive is identified and an action to meet the need. A person centred approach to meeting needs must be developed in terms of incorporating the person’s likes, dislikes and preferred routines. Along with evidence of the person’s participation in the care planning process, through their signature. It was understood from the staff that an keyworker system is in operation at the home. Residents consulted were aware of their keyworkers and could describe the roles undertaken. Glebe Villa D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 10 Running reports describe the staff’s observations of the persons, outcomes of visits and activities undertaken. The Confidentiality policy is included in the staff’s terms of employment, which is based on the records kept at the home. Detailing the measures in place to ensure the safety of the records kept at the home. Along with the implications to the staff that breech the policy. Glebe Villa D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 14 & 17 Residents are supported to use practical life skills at the home and staff assist residents with financial problems. Residents engage in leisure activities with staff and independently. Meals served at the home are varied and nutritional. EVIDENCE: One resident consulted during the inspection reported that staff have assisted with budgeting and for the first time has savings. Members of staff have assisted residents with finance problems and provide support with budgeting for example, daily budgets and bus passes. Residents participate in a range of community-based activities, which include employment, college courses and day centres. Previously residents left the Glebe Villa D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 12 home at 7:00 am for their days activities. The three residents that travel independently stated that their bus passes can only be used from 9:00 am onwards. Three residents reported that they are able to organise their leisure activities and holidays, with the other three residents supported by the staff. It was understood from the residents that the member of staff rostered on Saturday’s arranges group activities. The Saturday activities are for the three residents that require staff assistance in the community, although the other residents can participate. One resident stated that the group would be going to the cinema, to watch a newly released film. From the discussions, the residents are clearly informed about the changes in staffing, structural changes and maintenance. It was understood from the residents that redecoration of two bedrooms would take place while they were on holiday. The residents conveyed information about the staff changes and intended increase in numbers. Residents made positive comments about the range of meals served at the home. Additional comments were made by the residents that staff cultural meals are also available to residents, developing residents taste. The record of food provided indicated that alternatives outside the rolling menu are served, whenever requested by residents. Fruit is available at all times for residents to have in order to maintain healthy eating regimes. The range of fresh, frozen and tinned foods indicated that residents have a varied and healthy diet. Glebe Villa D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 & 20 Members of staff provide minimal support, as the residents are independent with personal care. Records must be more specific in the support and prompting provided by the staff. Safe practices of medication exist and profiles must be completed. EVIDENCE: Residents currently accommodated are independent with personal care; members of staff provide minimal support. It was understood from the staff that three residents are assisted by the staff to wash their hair. This is not described in their care plans. Where residents are supported or prompted by the staff to complete tasks, their care plans must detail the level of assistance provided. From the records, it is evident that one resident requires supervision from staff to purchase clothing. The care plan must therefore describe the support that the staff must provide to the person. Case records contained documentation from outside agencies, evidencing that specialist support is sought, where necessary. Residents described the personal tasks that staff undertake. Residents currently accommodated are fully ambulant and do not require the property to be adapted. Glebe Villa D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 14 Three residents have regular prescribed medications, which the staff administer. From the records of administration it is clear that staff sign the administration sheets immediately after administration. Individual profiles that explain the purpose of the prescribed medication, their side effects and compatibility with homely remedies must be developed. Glebe Villa D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 Residents confirmed that complaints are taken seriously by the staff and action is taken to resolve their complaints. A log of complaints received must be maintained. Protection of Vulnerable Adults training attended by the staff has established a multidisciplinary approach to protecting residents from abuse. EVIDENCE: Residents consulted were clear on the procedure for making complaints. They expressed their confidence in the staff’s abilities to resolve their complaints. It was understood from the staff on duty that although complaints and concerns are discussed during meetings, a complaints log is not maintained. A complaints log must be maintained, with an analysis of complaints received through residents meetings. Members of staff are attending the POVA workshops provided by the Local Authority. This evidences a commitment to working within a multidisciplinary framework in order to safeguard residents from abuse. Glebe Villa D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not examined at this inspection EVIDENCE: Glebe Villa D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34 & 35 Members of staff have demonstrated their competency and skills. Significant changes have occurred with staff changes and a more stable team must be developed. Members of staff are clear on their responsibilities and have specific knowledge of the residents needs. Staff’s records evidenced a robust recruitment process. There is a training programme in place at the home. EVIDENCE: The rota in place indicated that three care assistants are employed at the home. As residents are away form the home during the day, members of staff are available in the event of any changes in residents routines. The rostered hours are generally for when residents are at home. While the rota indicated that the home is staffed between 3:00pm-11:00pm and 11:00pm –9:00am, staff were at the home for the unannounced inspection at midday. An on-call procedure must be developed to ensure that in the event of an emergency, staff can be contacted. There have been significant changes with the staffing at the home and more changes are to take place. One senior carer will be transferring within the Glebe Villa D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 18 organisation and another has been appointed. Residents consulted were aware of the changes and commented on their disappointment at this staff’s leaving. Two staff meetings occurred in March with the manager and senior staff. The agenda covered training, residents meetings and inductions. One member of staff is currently undertaking the Bristol City Council induction and LADF foundation with the NVQ following. One person communicates in Makaton and guidelines with symbols for staff to communicate with the resident. Members of staff are registered on Understanding Positive communication training. It is evident that the staff have basic skills in communicating with the resident. The service provider must assess the benefits of staff undertaking Makaton training. Staff’s personnel files were examined and with the exception of one person, documentation included evidenced compliance with Schedule 2. One file required the persons photograph to be included. There is a training programme in place for the senior care assistants and service provider. POVA, LDAF, advocacy, Challenging Behaviour, Equalities and Supervision are training organised for this year. Glebe Villa D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 41 & 42 Records examined are accurate and up to date. These relate to finance and safety. EVIDENCE: Three residents currently have cash in safekeeping, and the records were up to date and reflected the balances held. The service provider must assess the benefits of opening bank accounts for residents that have large sums of money in safekeeping. The records that relate to fire safety policies, procedures, checks and practices were examined. From the records it is evident that checks and practices are conducted at the stipulated frequencies. Outside contractors conduct annual fire safety system and extinguishers checks. The Public Liability Insurance certificate and CSCI certificate are displayed in the home. Glebe Villa D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 20 An Environmental Health officer visited the home and the staff at the home followed the advice given. It was understood from the staff that the COSHH cupboard is outside the home. Glebe Villa D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x x Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x x 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x 3 x 3 x x 3 Standard No 31 32 33 34 35 36 Score x 2 3 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Glebe Villa Score 2 x 2 x Standard No 37 38 39 40 41 42 43 Score x x x x 3 3 x D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 22 yes Are there any outstanding requirements from the last inspection? 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 Standard 1 Standard 6 Regulation Regulation 4 Regulation 15 Requirement Timescale for action 30/12/05 30/12/05 3. Standard 20 4. Regulation 22(3) 5. 6. Regulation 18 REgulation 7,9,19 Schedule 2 The Statement of Purpose must be further developed. A person centered approach must be adopted for care plans. Including the promts and asssitance provided by the staff. With residents participations evidenced on the care plan Regulation Medication profiles that describe 13 the purpose of the prescribed medication must be devised. With their side effects and compatibility with homely remedies. Standard A record of complaints received, 22 which includes the nature of the complaints, the investigation, outcome and level of satisfaction must be maintained. Standard An on-call procedure must be 32 developed in the event of an emergency. Standard Staff records must include a 34 recent photograph. 30/10/05 30/10/05 30/10/05 30/10/05 Glebe Villa D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 23 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 Good Practice Recommendations Glebe Villa D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 24 Commission for Social Care Inspection 300 Aztec West Almondsbury South Gloucestershire BS32 4RG 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 Glebe Villa D56_D05_S61212_Glebe Villa_V241858_020805_Stage4.doc Version 1.40 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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