Inspection on 27/01/06 for Glebe Villa

This inspection was carried out on 27th January 2006.

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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glebe Villa 24/06/08

Glebe Villa 22/06/07

Glebe Villa 09/06/06

Glebe Villa 02/08/05

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 Inspection 27 January 2006 09:30 th Glebe Villa DS0000061212.V276244.R01.S.doc Version 5.1 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 Glebe Villa DS0000061212.V276244.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Glebe Villa DS0000061212.V276244.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Glebe Villa Address 26 Glebe Road St George Bristol BS5 8JH 0117 9541353 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) Aston Care Homes Mrs Etylin Astbury Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Glebe Villa DS0000061212.V276244.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 6 persons with learning disabilities aged 18 64 2nd August 2005 Date of last inspection 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 DS0000061212.V276244.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection is the second for the year 2005/2006, conducted on an unannounced basis. There were no additional visits to monitor compliance with the legislation since the last inspection. There were five residents at the home during the inspection and their feedback on the standards of care was sought. What the service does well: What has improved since the last inspection? What they could do better: Two requirements are outstanding from the last inspection and focus on developing person centred plans and medication profiles. Glebe Villa DS0000061212.V276244.R01.S.doc Version 5.1 Page 6 It is of concern that the service providers presence is at weekends and includes sleeping-in, which gives little opportunity for monitoring consistency. For this reason, a requirement was made to provide an action plan on the arrangements for the day to day management and for monitoring consistency of care. To achieve approval with the increase in numbers to be accommodated, the service providers must provide documentation that evidences compliance with the Care Standards Act and associated legislation. The staff at the home must conduct emergency lighting checks monthly to promote a safe environment to residents. 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 DS0000061212.V276244.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Glebe Villa DS0000061212.V276244.R01.S.doc Version 5.1 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 the following standard(s): These standards were not examined at this inspection. EVIDENCE: Glebe Villa DS0000061212.V276244.R01.S.doc Version 5.1 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 the following standard(s): 6, 7 & 9 A person centred approach to meeting needs must be developed which specifies the individuals abilities to make decisions and which includes the communication needs of the resident that uses Makaton. Risk assessments in place endeavour to reduce the level of risk. Strategies that relate to mental health needs must include the key words that trigger a positive response. EVIDENCE: Care plans are signed by the resident to indicate their awareness and agreement with the action plan. While there is information at the home about developing a person centred approach to meeting needs, person-centred plans are yet to be formulated. In developing person centred plans, records will include the individuals abilities to make decisions, with the support that staff will provide to empower residents. For the resident that uses Makaton to communicate, the means used to communicate must be specified in the care plan. Glebe Villa DS0000061212.V276244.R01.S.doc Version 5.1 Page 10 Reports of significant events describe residents daytime activities and any changes to daily routines. Risk assessments are completed for activities that may involve an element of risk. Within the assessments there is a description of the potential risk involved and the action to be taken to reduce the level of risk. For one resident that may become depressed, the guidance to staff is not specific in terms of key words that trigger behaviours. Other risk assessments based on Health and Safety are completed. Glebe Villa DS0000061212.V276244.R01.S.doc Version 5.1 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 the following standard(s): 13,15 & 16 Residents access community facilities independently and staff support residents to use local amenities. Members of staff ensure residents maintain links with family and friends inside and outside the home. The rules and routines of the home ensure that staff respect residents rights and individuality. EVIDENCE: Three residents currently travel independently when outside the home while the other three are supported by staff. Care plans specify the individuals needs and their level of independence outside the home. Residents access the local library, restaurant, parks, cinema and shopping independently and with staff. Concessionary passes were sought for residents to use public transport with staff support. Glebe Villa DS0000061212.V276244.R01.S.doc Version 5.1 Page 12 Care plans list the individuals responsibility for household chores, there is an expectation that residents clean their bedrooms and personal laundry. There is also a schedule of chores on display in the kitchen and generally residents complete their allocated chores on set days. Chores completed by residents consist of loading the dishwasher, cleaning personal and shared space. Comments made by residents indicated staff input is dependant on their level of abilities. Bedrooms are lockable and residents are provided with keys to their bedrooms and front door. Their mail is handed unopened and residents approach staff for assistance with reading. It was understood from the member of staff on duty that there are no restrictions imposed on choice and freedom. Two residents currently smoke and are permitted to smoke outside only. Residents consulted confirmed that their family and friends are welcome by the staff at the home. Additional comments were made about the Christmas party that their family and friends were invited. It was reported that never before were families invited to celebrate special events, at the home. Since the last inspection residents have gone on holiday with two members of staff. Residents giving feedback explained that generally three residents have independent holidays without staff support. On this occasion the group went together and comments suggest that in future, the resident group will be going together with the staff. Glebe Villa DS0000061212.V276244.R01.S.doc Version 5.1 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 the following standard(s): 19 & 20 There are opportunities for residents to manage their own health care. Medication profiles must be developed to develop safe practices of medication administration at the home. EVIDENCE: Three residents visit their GP’s independently and staff accompany the other three residents. This suggests that there are opportunities for residents to manage their own health care. Case records evidenced that residents access local NHS facilities, regular visits are arranged to the opticians, dentist and chiropodists. Female residents are invited for routine screening and one person refused the invitation. Three residents are on regular prescribed medication, one person self medicates and staff administer medication to two residents. Records of administration indicated that staff sign the records immediately after administration. Medication leaflets are available for prescribed medications, Glebe Villa DS0000061212.V276244.R01.S.doc Version 5.1 Page 14 profiles must be developed describing the purpose of the medication, the side effects and compatibility with homely remedies. Glebe Villa DS0000061212.V276244.R01.S.doc Version 5.1 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 the following standard(s): 22 Residents have a clear understanding of the complaints procedure and expressed confidence with staff’s abilities to seek their views. EVIDENCE: The complaints and incidents record was examined during the inspection. It is evident from the records that two incidents were recorded since the last inspection. One occurred away from the home and the other was an accident involving a resident and member of staff. Comments made by residents evidenced that members of staff would be approached with complaints. Residents giving feedback expressed confidence with staff’s abilities with resolving complaints. Glebe Villa DS0000061212.V276244.R01.S.doc Version 5.1 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 the following standard(s): 24, 26 & 27 To achieve approval to increase the number of people that can be accommodated, written confirmation of compliance with associated legislation must be provided. The recent upgrading of the premises have provided residents with a better environment. There are sufficient number of toilets and bathrooms for residents, which respect residents right to privacy and dignity. Residents rooms reflect their lifestyles and personalities, with suitable furniture to meet their needs. EVIDENCE: Aston Health Care (registered providers) have applied for a variation to increase the accommodation. The intention is to increase the number of people that can be accommodated at the home from six to seven. The extension is attached to the rear of the property and will be converted into the kitchen, changing the uses of the laundry, kitchen and dining room. The dining room will be converted into an en-suite bedroom, with an additional downstairs toilet for the residents. The existing kitchen will become the dining room and Glebe Villa DS0000061212.V276244.R01.S.doc Version 5.1 Page 17 the laundry room will also function as an office. Plans were provided with the application form and copies of consent for the extension to be erected with certificates from other agencies must be provided. To achieve approval to offer accommodation for an additional person, evidence of compliance with other relevant legislation must be provided. Food Safety, Health and Safety, and Fire Regulations as well as NMS Planning and/or Building legislation must be confirmed in writing. It was noted during the inspection that the fire escape from the first floor to the rear of the property had been removed. Fire Authority permission must be evidenced to ensure that the means of escape are appropriate in the event of a fire. Since the last inspection two rooms were completely refurbished. In room 3 the windows were replaced and fitted cupboards installed. The walls were repainted and carpet renewed which has improved the environment for the person in the room. The double room used by a couple that cohabit has been extensively reorganised. The en-suite was re-sited to install a shower; walls repainted, carpet replaced and new furnishings purchased. Since purchasing the property the service providers have systematically redecorated personal and shared space providing a better environment for the residents. With the exception of one all rooms are single, one room is a double room, which is used by a couple that cohabit. All rooms are lockable and residents confirmed that keys to their rooms and the house were provided. Bedrooms contain a combination of the home’s furniture and residents personal belonging and reflect their personalities and interests. It is evident that rooms meet the individuals lifestyle and needs. As the double room and one single room is en-suite, three residents share the full bathroom. The bathroom has a toilet, with a separate W/C on the first floor providing a ratio of 2:2. In adapting the property a toilet will be provided on all bedroom floors and the ratio will increase to three toilets shared by two residents. Glebe Villa DS0000061212.V276244.R01.S.doc Version 5.1 Page 18 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not examined at this inspection. EVIDENCE: Glebe Villa DS0000061212.V276244.R01.S.doc Version 5.1 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38,41 &42 An action plan must be forwarded to the CSCI on the arrangements for the day-to-day management of the home and systems for monitoring consistency of care. To maintain a safe environment for the residents accommodated, emergency lighting checks must be conducted monthly by the staff at the home. Records that relate to food served and cash in safekeeping were accurate and up to date. EVIDENCE: The rota in place indicated that the service providers are rostered at the weekends and during the week one person is rostered. While the service providers cover 30 hours per week including night cover, one person is on duty for significant periods during the week. Realistically staff are having little day to day support and there is little management presence during the week. The service provider must provide the CSCi with a management plan. The plan Glebe Villa DS0000061212.V276244.R01.S.doc Version 5.1 Page 20 must include the arrangements for the day-to-day running of the home and the way that systems for consistency are monitored. Facilities exist for the safekeeping of cash and valuables at the home and currently one person has cash in safekeeping. The records of cash balances were checked and found to be consistent with the cash held in safekeeping. Receipts are appended onto the records and evidence purchases made on behalf of the resident. The records of fire safety systems checks and practices were examined. With the exception of the emergency lighting checks, checks and practices are conducted at the stipulated frequencies. A record of the food provided is currently maintained which confirms that three meals are served to the residents at the home. A varied and nutritious diet is served at the home. Glebe Villa DS0000061212.V276244.R01.S.doc Version 5.1 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 Standard No Score 1 x 2 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 x ENVIRONMENT Standard No Score 24 3 25 x 26 3 27 3 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 x 33 x 34 x 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 2 x LIFESTYLES Standard No Score 11 x 12 x 13 3 14 x 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 2 x x 2 x x 2 2 x Glebe Villa DS0000061212.V276244.R01.S.doc Version 5.1 Page 22 no 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 Standard YA6 Regulation 15 Requirement A person centred approach must be adopted for care plans. Including prompts and assistance provided by the staff. Evidencing resident participation. (Previously required 02/08/05) Medication profiles that describe the purpose of the prescribe medication must be devised. Side effects and compatibility with homely remedies must be described within the profiles. (Previously required 02/08/05) Individual risk assessments must include key words that trigger positive responses. Documentation that evidences compliance with Care Standards Act and other associated legislation must be provided in advance of any increase in numbers The service providers must provide an action plan on the day-to-day management of the home and the systems in place to monitor consistency. DS0000061212.V276244.R01.S.doc Timescale for action 30/04/06 2 YA20 13 30/03/06 3 4 YA9 YA24 13(4) 16(2) 30/04/06 30/04/06 5 YA37 10(1) 01/03/06 Glebe Villa Version 5.1 Page 23 6 YA42 17(2)Sch.14 The staff at the home must conduct emergency lighting checks monthly. 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Glebe Villa DS0000061212.V276244.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos 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 DS0000061212.V276244.R01.S.doc Version 5.1 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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