Inspection on 05/05/05 for Primrose Villa

This inspection was carried out on 5th May 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Primrose Villa 31/10/06

Primrose Villa 06/12/05

Primrose Villa 01/12/04

Primrose Villa 02/06/04

Similar services:

32 Beaumont Way

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

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

CARE HOME ADULTS 18-65 Primrose Villa 250 Fishponds Road Upper Eastville Bristol BS5 6PX Lead Inspector Karen Walker Unannounced 05 May 2005 09:30 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. Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Primrose Villa Address 250 Fishponds Road Upper Eastville Bristol BS5 6PX 0117 9519481 0117 9519481 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) Parkcare Homes (No 2) Limited Ms Carol Clay PC Care home 8 Category(ies) of LD(E) Learning disability - over 65 (2) registration, with number LD Learning disability (6) of places Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 6 persons aged 18 - 64 years May accommodate up to 2 persons aged 65 years and over Date of last inspection 1 December 2004 Brief Description of the Service: Primrose Villa is registered to provide accommodation to six people aged 18-64 and two people aged over 65 years with learning disabilities. The home is operated by Parkcare Homes (no 2) Ltd (a wholly owned subsidiary of Craegmoor Group Ltd). The double room has converted to a single. Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector gained the information necessary to inform this report through case tracking, talking to residents’ and staff and through discussions with the home manager. The appropriate records were also examined. What the service does well: What has improved since the last inspection? What they could do better: The environment is in need of refurbishment and there are areas that require attention to ensure the safety of residents’ an example of this is the back step, which is unstable, and the bathroom floor that is rising with bowing rotten wood. Attention must be given to recruitment practices and the checking of references to ensure residents’ are protected by robust recruitment procedures. Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 Page 6 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. Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 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 Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 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) 1,2,3,4,5 Residents’ are well informed and encouraged to make life-altering decisions within a ‘safe environment’. EVIDENCE: The newest resident to join Primrose villa was case tracked and it was explained to the inspector that she did not yet have a contract. This was due to still undergoing a probationary period to ensure all parties are happy with the placement. Other contracts were seen and it was noted that these were not user-friendly. It is strongly recommended that contracts are accessible to each individual. It was noted that the appropriate healthcare referrals were made and it was evident that there was an element of choice in healthcare provision. A copy of the service user guide and complaints procedure has been given to the resident. Records show that the ‘move in’ was gradual starting with a visit only this was followed eventually with a weekend stay. Correspondence shows a placement review meeting is due to take place, which includes all relevant people as identified by the resident. The manager confirmed she ‘asked permission’ to also attend. The inspector saw a detailed assessment carried out by social services and it was confirmed by the resident’s key-worker that gradual progress was being made with the appropriate goal planning and risk assessing. Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 Page 9 Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 Page 10 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) 6,7,8,9 Residents are aware of their assessed needs and are given the opportunity to make decisions about their own lives. Residents’ are consulted on household issues and are supported to take necessary risks to enable as independent life as is possible. EVIDENCE: One resident talked through his updated care and goal plan. He confirmed he kept a copy of the service user guide and his goal plans in his room for reference. It was evident that as needs change the care plan is updated to reflect the level of support needed. The inspector saw some excellent goal plans, which involved ‘goal steps’ leading to the ultimate goal. This ensures each step is achievable and limits the possibility of ‘failure’. There were many risk assessments in place that enabled and empowered residents’ to carry out everyday tasks as well as to ensure support with highlighted ‘social needs’ i.e. managing behaviours that may challenge. One resident said he chose his key-worker and was quite happy. This is seen as a step forward for this resident who usually only chose a manager. Residents meetings take place on a regular basis and the minutes show that all residents are encouraged to attend and have an input. Residents’ were asked Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 Page 11 as a group of people how they wish to be addressed the majority chose the term ‘residents’. Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 Page 12 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) 11,12,13,14,15,16 Residents’ are given opportunities for personal development and for the involvement in recreational activities. Residents’ are supported with maintaining relationships and are encouraged to be a part of their local and wider community. EVIDENCE: All residents have a full activities programme relevant to their needs and preferences. One resident showed the inspector the certificates he had gained these included; infection control, fire training, first aid, manual handling, food hygiene and COSHH. These training certificates are particularly relevant to this resident who enjoys doing his own cooking and making his own decisions regarding healthcare. He enjoys DIY and identified the need for first aid and manual handling training. It was evidenced to the inspector that those residents who chose to stay mainly at home were offered appropriate activities. The manager explained that the home was offering an activity programme to other homes with a small charge. This would then be used to offer day trips and outings or buy materials Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 Page 13 needed for recreational activities. The manager will monitor the progress of these activities and consult with residents’. The inspector has observed residents in various relationships and noted that friends and family members are always welcomed into the home. Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 Page 14 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) 18,19,20 Residents are able to take control of their own healthcare needs and make informed decisions relevant to them. Residents’ are supported in the way that they chose. EVIDENCE: It was noted and residents confirmed that times for getting up and going to bed were flexible. The inspector saw that each resident had individual choice on what to wear. At the last inspection one resident returned from a shopping trip and was pleased to show the inspector and staff the new clothes she had bought and chosen for herself. Specialist support is gained where necessary including input from physiotherapists, occupational therapists, continence advice etc. Records show that that each resident has a key-worker and is happy with their choice. Personal support is provided in private. The inspector noted that when residents’ want to discuss something relevant only to them they are advised to talk in the office or away from others for privacy. The inspector noted that care plans detail the support needed to access NHS healthcare facilities. Records show that residents attend various health care appointments as is necessary. Visits to the dentist, general practitioner and optician take place on a regular basis. One resident confirmed that visits to the Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 Page 15 asthma clinic now take place, the asthma is controlled and the nurse is happy with his progress. Regulation 37 notifications are sent appropriately to the CSCI. Records show that residents are encouraged and enabled to administer their own medication where possible within a risk-assessed framework. The inspector took the opportunity to check the balances of two PRN medications and found both to be correct. Medication policies and procedures are in place and one staff member confirmed she was aware of them. This ensures a safe system for the administration of medication. Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 Page 16 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 feel their views are listened too and acted upon. Residents are protected from abuse and harm. EVIDENCE: Complaints are discussed at residents’ meetings where all residents’ are asked if they have a complaint or concern. This is good practice and ensures residents’ concerns are listened too. One resident spoken with said he has a copy of the complaints procedure in his room and would have no hesitation in making his views known. This resident told the inspector of a complaint he had recently made and was satisfied with the outcome that he received in writing. The manager confirmed all staff were familiar with the POVA policy and had a clear understanding of what could constitute abuse and how to deal with allegations of abuse. The whistle blowing policy and the ‘no secrets’ policy was also available. Abuse awareness training has been provided by Social services. The manager also said that POVA awareness training would be undertaken on an annual basis. Any behaviour that may be seen as challenging including verbal and physical aggression are identified and highlighted in individuals care plans and linked to risk assessments. One resident told the inspector he was aware of his ‘behaviours that challenge’ strategy plan. The inspector took the opportunity to sample check the finances kept in the home for 3 residents. All records checked were correct at the time of inspection. Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 Page 17 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) 24,25,26,27,30 Residents’ do not live in a totally safe and comfortable environment. Much work needs to be carried out to ensure the environment is in an adequate state of repair. Residents’ rooms are individualised and there is adequate shared space that is utilised by the residents’. EVIDENCE: Although the boiler has had a new timer in place the manager reported that the water still couldn’t be heated without the central heating being on. This must be addressed and the manager said she would contact the company responsible for the repairs that failed to return on the date given. The inspector suggests that Craegmoor cease to do business with this firm, as they are unreliable. The kitchen cupboards are in need of repair or replacement and a recent inspection by environmental health highlighted similar issues. It was noted that the kitchen flooring is rising at the edges providing areas for bacteria to flourish. Worktops are stained and have burn marks on them. The manager confirmed the kitchen was put in originally in the 1980’s and one of the resident’s has attempted to ‘tidy it up’. Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 Page 18 It was noted that the home is without a dishwasher and residents’ have requested one. This is highlighted in residents’ meetings minutes. The inspector strongly recommends that a dishwasher be purchased to ensure food hygiene requirements are adhered too. The manager confirmed the lounge/diner carpet was to be replaced. In some places the carpet in the hallway has been worn of its pattern. It would benefit the home and residents’ to have new hall, stairs and landing carpet. The upstairs bathroom had an unpleasant odour at the time of inspection and it was noted that the flooring was lifting and the board underneath was bowing it appears rotten. This room would benefit from total redecoration. The shower room however is being redecorated and wooden cladding added. There are adequate bathing facilities and toilets available to residents. The inspector noted that the external ‘step’ leading into the garden remains ‘wobbly’ and in the inspectors opinion is unsafe, this area would also benefit from a handrail. It must be made safe and accessible to residents who require support with mobility. The issue of the uneven and pot holed lane remains an issue but the manager said a quote has been presented to Craegmoor who are considering tarmacking the lane and providing lighting. This will be of great benefit to the two Craegmoor houses that share this access. Residents’ rooms are individualised and contain adequate furnishings. Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 Page 19 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) 32,34,35,36 A supported and supervised staff team supports residents. Residents were not protected by a robust recruitment system but this is being rectified. Residents are supported by an appropriately trained staff team, which continues to improve. EVIDENCE: The inspector took the opportunity to examine two sets of staffing records. It was noted that the induction and foundation training programmes had been undertaken. Foundation training for one staff member was carried out in just one day. Records show that Foundation training consists of 5 sections including developing as a worker, understanding how to apply the value base of care, how to communicate effectively and recognising and responding to abuse. This was recorded as being carried out in-group discussion. It is evident that these subjects require more than one-day discussion to enable the staff member to have a true understanding of the subject matter and a better input to resident care. It is strongly recommended that this practice of one-day foundation training be reviewed. Training needs were identified by the manager and in supervision sessions and training accessed accordingly. Supervision sessions are planned every 6-8 weeks and are identified on an annual plan. Staff members have a contract of employment and 2 references were sought in respect of them. However it was noted that one set of references were both Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 Page 20 negative and both referees said they would not re-employ the person. There was no evidence of why the decision was taken to employ. Although the manager said this had been recognised It is a requirement that if a decision is taken to employ a person with poor references a record must be kept of the extenuating circumstances. Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 Page 21 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) 37,38,40,42,43 Residents’ benefit from a well run home where there are ample policies and procedures available to safeguard their rights and interests. The health and safety of residents’ is promoted and monitored. EVIDENCE: The registered manager has returned to the home after taking on the role of General Manager. The residents have seen much change in the way of acting managers and it will now benefit residents’ and staff to have continuity in management. Records show that safety checks take place within required timescales e.g. annual portable appliance testing (PAT), gas check and water tank check. The fire logbook was also examined and all relevant fire checks and training were carried out in the timescales as recommended by the Avon Fire Brigade. It is recommended that names of those staff that have carried out the appropriate fire training be added to the fire logbook for ease of tracking. Currently records are kept in the appropriate staff file. At the last inspection the inspector saw many organisational policies and procedures as well as in-house policies. One resident told the inspector he was Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 Page 22 aware of a number of policies and confirmed he understood the complaints policy. The manager said she receives an operation plan on a monthly basis this details expenditure to date and any overspend. Areas of the budget are then discussed with the area manager. The inspector noted the certificate of insurance was in place alongside the registration certificate. There are clear lines of accountability in the home both residents and staff are aware of. Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 Page 23 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 3 3 3 3 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 3 3 x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score x 3 x 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Primrose Villa Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 3 3 3 D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 Page 24 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 24 Regulation Requirement Timescale for action 1/9/05 2. 3. 4. 5. 24 24 24 34 23(2)(b)(c Replace the kitchen cabinets etc ) which are beyond repair and attend to the works highlighted by the Environmental Health Officer. 23(2)(b) Make safe the back step and concider adding a handrail. 23(2)(b) investigate the bathroom flooring and repair and replace as neccessary 23(2)(b) repair or renew the hall, stairs and landing carpet 19(1)(a) The registered person shall not employ a person unless they are fit to work in a care home. Stringent records of decisions to employ must be kept. 1/8/05 1/8/05 1/10/05 1/6/05 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. 2. Refer to Standard 5 24 Good Practice Recommendations make contracts accessible to each individual purchase a dishwasher to improve health and safety requirements. Version 1.30 Page 25 Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Commission for Social Care Inspection 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 Primrose Villa D56_26549_PrimroseVillas_225923_050505_Stage4.doc Version 1.30 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!