Inspection on 02/02/07 for Primrose Place

This inspection was carried out on 2nd February 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Primrose Place 27/01/09

Primrose Place 20/02/06

Primrose Place 20/06/05

Primrose Place 03/03/05

Primrose Place 14/12/04

Primrose Place 29/12/03

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Primrose Place 34 Somerset Road Handsworth Birmingham West Midlands B20 2JD Lead Inspector Nancy Johnson Key Unannounced Inspection 2nd February 2007 09:30 Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Primrose Place DS0000016974.V326725.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 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. Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Primrose Place Address 34 Somerset Road Handsworth Birmingham West Midlands B20 2JD 0121 554 0440 0121 241 2597 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) Mr David Cobley Mrs Nelam Kaur Mr David Cobley Care Home 5 Category(ies) of Learning disability (5), Sensory impairment (5) registration, with number of places Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 20th February 2006 Brief Description of the Service: Primrose Place is a Victorian style semi-detached house located in Handsworth Wood. It lies in a quiet residential neighbourhood, close to local amenities including shops, parks and bus routes. The service offers quality accommodation for up to five adults with sensory impairment and/or learning disabilities. There is a comfortable service users lounge with sensory equipment and large separate dining and activities room with a piano. There is a kitchen, which service users can access. A separate laundry room is at the rear of the kitchen. There are five single bedrooms, three of which have ensuite facilities. Those service users who dont have these facilities have access to a bathroom and separate toilet. Off road, Parking is available for one car at the front of the house. To the rear of the house is an easily accessible garden with a lawn, shrubs and trees. There is also an attractive blocked paved area leading to the summerhouse. The home is decorated in bright colours with touch indicators in the ledges and handrails to enable service users who are visually impaired to get around the premises. Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection took place with one inspector. Documents pertaining to residents were sampled, including care plans, health action plans, Quality Assurance, Risk Assessments and Health and Safety. Discussions were held with the Deputy Manager and staff. The inspector also observed interaction between residents and staff. The majority of standards across outcome groups were measured by the inspector. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 Page 6 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 Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 Page 7 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are able to ‘test drive’ the service prior to admission and their compatibility with the service and other service users is assessed before a decision is made as to their suitability. Each service user has an individual statement of terms of conditions with the home. EVIDENCE: The home has a Statement of Purpose and the Service Users Guide has recently been reviewed, however no amendments have been made therefore the existing documents are still fit for purpose. Both documents are available in large print. Video and audio format can be obtained upon request. Prospective service users must be reasonably compatible with other residents in order to be placed within the home. They are able to ‘test drive’ the residence prior to admission. The inspector found that social workers had provided the service with initial assessments and initial care plans prior to admission. Comprehensive care plans and risks assessments were developed for each resident. Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 Page 8 The service users were encouraged to contribute towards decisions affecting the day to day running of the home and were involved in menu planning. Menus are done on a four weekly rotation basis. Pictorial information is used in assisting residents to select meals of their choice. The Inspector sampled three of the service users case records and all had detailed care plans covering areas such as life skills, visual impairment, behaviour management, dietary requirements and communication. Each file also contained their individual written contract. There is a key worker system in place and plans are reviewed monthly. This is evidenced by case tracking of residents and staff meetings. Although the home would like to involve the residents in regular house meetings, this is not usually possible due to the complexity of their disabilities. Records seen showed that residents were supported in terms of physical and mental health needs, for example regular chiropody appointments, dental appointments and links with other professional services. Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users were each assessed and a detailed care plan drawn up to assess their individual needs. Staff encourage and support service users to make their own decisions. Risk assessments were undertaken and were well documented to ensure the safety of service users. EVIDENCE: Each service user has a detailed care plan and those sampled by the inspector contained details of the service users daily activities, teaching programmes and independent living skills programme. Files were well organised and up to date. There was evidence to confirm that the service users families had involvement in reviewing these programmes and looking at new goals. Service users also take part in leisure activities such as shopping, photography and attend their local library. Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 Page 10 Service users files also contain their Health Action Plan. Each entry is signed and dated by the key worker and resident. The plan contains details of medical visits and their weight is monitored monthly. Each file contained detailed risk assessments covering bathing, community and escorting activities. Decision making was made with the service users on a daily basis and the service user was assisted with this by the staff. Some service users required the aid of communication cards. There was a behaviour management programme in place for reach resident which clearly outlines the aim of the program, types of behaviour to be discouraged, triggers, responses. For negative consequences the approach used for one individual was the withdrawal of all non- essential attention (30 minutes time out), which was agreed with relevant professionals . This program was regularly monitored and the last review was October 2006. Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are part of the community and engage in appropriate leisure activities. Weekly activities were planned and personal goals were made and reviewed on a regular basis. EVIDENCE: Service users were encouraged towards independent living and their care plans detail goals that each user is working towards. One such user has a goal of making regular visits to the local library. The home has good community links and activities were provided through the home and outside agencies. Service users visit the local parks, swimming facilities and shop in the local area. Family and friendships were encouraged and visit; most service users have regular visitors. Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 Page 12 The Manager advised the inspector that great use was made of their garden facilities and during the summer months they have regular barbeques. Each service user has an Essential Lifestyle Plan (ELP) which was easy to access and provided specific information as to the users likes and dislikes, what was important to them, who they knew and people that cared about them. The ELP contained a “bank of experience” i.e., outings and special experiences were highlighted. It also included details of how they wished to communicate. Residents were encouraged to maximise their skills. For example, one of the residents plays the piano and the recorder and during the inspectors visit they provided entertainment for the home which both staff and residents enjoyed. Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported and are able to make decisions about the level of support they require in their personal care. Effective management and policies are in place to support the health, welfare and independence of the service users. EVIDENCE: Each user has their own comprehensive health plan in line with the government white paper “Valuing People”. The inspector was easily able to access and audit the well kept records. Detailed information was provided in the sampled files as to the service users access to healthcare services. Each service user had different needs in terms of personal care and they were involved in decision making as to the amount of assistance they require. There were detailed risk assessments on sampled files for the movement of service users in relation to personal hygiene. Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 Page 14 Service users weight is monitored on a monthly basis and general health details are also recorded. Action plans are documented if a health issue needs to be addressed. All staff have received Medication training and management of medication is good. Managers ensure that medication is documented with the Medicines Administration Records (MAR) prior to being administered to the service users. A copy of each prescription is kept on file. Administration of medication signed by two staff. In addition, audits are carried out by the Deputy Manager and a record is included in each workers file. This is part of the home’s Quality Assurance Measure as well as a tool used to assess for training and assessment needs. Service users wishes are listened to and respected. This was apparent by documentation within a service users file which indicated that they had purchased a burial plot which meant that they would be buried close to their family members. Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No complaints have been received by CSCI in the last 12 months. The home has a clear complaints procedure. All staff have received Adult Protection Training and CRB and POVA records were found on staff files along with the appropriate proof of identity, application forms and references. However, the Inspector found that there were three CRB checks that were in excess of four years. Good practice would suggest that these should be renewed on a three yearly basis. The home is annually quality assured by Visibly Better, an external body that runs an accreditation scheme operated by the RNIB. They undertake a comprehensive annual assessment against a wide range of standards for visibly impaired people. The home also undertakes a yearly internal quality survey to obtain views from staff, relatives, advocates, and other visiting professionals. The survey covers the quality of environment, staff, care and management. This is used to obtain feedback so that the service can be improved. All service users have personal inventories of their belongings and any valuables including bank information and passports are kept in the safe. These are regularly reviewed and updated. Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 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. Service users live in a homely and well-maintained environment. Their individuality is promoted in terms of personalised rooms which are equipped to meet their needs. EVIDENCE: The home was welcoming, clean and no unpleasant odours were detected on a tour of the home. There are grab rails located in hallways and bathrooms to assist with mobility and the premises are pleasantly decorated. The rear garden was well maintained and the inspector was informed that great use was made of the space especially in the summer months. Residents were able to move freely around the home. All bedrooms were decorated to a good standard and were individualised according to the service users needs and lifestyles. Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 Page 17 Health and safety policies are in place and adhered to. All health and safety checks have been carried out within the required timescales and certificates are in place. The Deputy manager has received training in portable appliances and these are checked annually. Any new appliances purchased are added to the records and checked accordingly. The home was visited recently by the Environmental Health Officer who recommended monthly freezer temperature checks for the large and small fridge. This has been introduced accordingly. Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff receive regular training to update their skills and the organisation is committed to staff development. The team is very stable with most staff having worked at the home for a number of years. Adequate staff are in place to meet the service users needs. Appropriate recruitment procedures and monitoring is in place to ensure the protection of the service users. EVIDENCE: Three staff files were sampled and contained application forms, POVA and CRB checks, proof of identity, photograph, references and contract. Two bank staff had left since the last inspection however staff turnover is very low. The home is committed to continual training and the staff had recently had training including courses in Violence, Aggression and Personal Safety, Visual Impairment and Nutrition in the Care Home. Further training was planned including Dealing with Challenging Behaviour and Medicine Management. Evidence of attendance was found on staff files. Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 Page 19 The service has links with the Royal National Institute for the Blind where staff undertake distance learning courses to deal with specific issues for service users with sensory impairment. Staff receive monthly supervision and an annual appraisal system is in place. However, the Manager and Deputy Manager do not receive supervision. The Deputy Manager has conceded that whilst they do take part in peer reviews of their performance this was an area that needed to be addressed. During the inspection it was quite clear from exchanges with staff that they were happy in their posts. Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 40, 41, 42, 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager ensures that the home is run very competently and to a good standard. His leadership promotes residents’ wellbeing. EVIDENCE: The Inspector found the Deputy Manager very co-operative and she seemed willing to take comments on board. Staff expressed positive comments regarding the service including one member of the bank staff who stated, “I think Primrose is a great care provider. The residents are well cared for and the ethos of the place is positive. The management approach is authoritative yet friendly.” Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 Page 21 Staff stated that communication between themselves and the Managers was good. Staff meeting take place on a regular basis. Both staff and service users appeared at ease with each other. Overall the atmosphere was warm and relaxing just like a family home. There is a clear policy in place for safekeeping service users valuables and the management of their finances. The registered Manager is the appointee for three of the residents and the remaining resident’s appointee is a family member. The inspector looked at all service users financial records and accounts were appropriately recorded and receipt of cash and expenditure were clearly documented. Policies and procedures are in place to protect and promote the safety and wellbeing of service users. Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 Page 22 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 3 2 3 3 3 4 4 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 4 26 4 27 3 28 3 29 3 30 4 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 X 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 4 3 4 3 X 3 3 3 3 Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA36 Regulation 10(3) Requirement A system of supervision to be implemented for the Deputy manager. Timescale for action 01/08/07 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 YA26 Good Practice Recommendations The home should ensure that good practice is followed in that CRB checks are renewed at least once every 3 years. Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Primrose Place DS0000016974.V326725.R01.S.doc Version 5.2 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. 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