Inspection on 06/12/05 for Primrose Villa

This inspection was carried out on 6th December 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Primrose Villa 31/10/06

Primrose Villa 05/05/05

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 Nicky Grayburn Unannounced Inspection 6th December 2005 09:30 Primrose Villa DS0000026549.V268692.R01.S.doc Version 5.0 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 Villa DS0000026549.V268692.R01.S.doc Version 5.0 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 Villa DS0000026549.V268692.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Primrose Villa Address 250 Fishponds Road Upper Eastville Bristol BS5 6PX 0117 9519481 0117 9519481 primrose.villa@craegmoor.co.uk 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) Parkcare Homes (No. 2) Limited Ms Carol Clay Care Home 8 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (2) of places Primrose Villa DS0000026549.V268692.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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 5th May 2005 Brief Description of the Service: Primrose Villa is registered with the Commission for Social Care Inspection to provide accommodation and personal care 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 home is situated on a busy road, in a residential area close to shops, bus routes and other local amenities. The property has a good-sized garden, a barn, and a garage. It is in keeping with the neighbouring properties. The home has six single rooms, one double, and one staff sleep-in room, all accessible by stairs. Primrose Villa DS0000026549.V268692.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out within one day. Previous requirements and recommendations were discussed. Time was spent with residents and the deputy manager. A ground floor tour was undertaken with a resident, and then the upper floors and outside with the deputy. Case tracking and documentation was examined. Verbal feedback was given to the deputy who made note of all issues. 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. Primrose Villa DS0000026549.V268692.R01.S.doc Version 5.0 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 Villa DS0000026549.V268692.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, 5 Potential residents have the relevant information to make an informed decision about whether to stay at the home. Contracts need to be understood by the resident to ensure that they are aware of the terms and conditions. EVIDENCE: The Statement of Purpose is kept in the porch area and gives visitors and residents the relevant information about the home. Service User Guides are kept in the resident’s personal files in a pictorial format, containing the complaints procedures and details of how to contact the CSCI. There is a summary of a previous report in the guide, however, it was from 2003 and would benefit from the summary of the latest report. The newest resident had an assessment and has since had a care review with the placing authority to ensure the home meets their needs. The previous inspection examined the admissions procedure for the newest resident. The admissions statement in the Service User Guide is clear and states that potential residents can have over night stays and ‘test drive’ the home prior to deciding whether to reside at the home. Where appropriate, contracts need to be signed by the resident to confirm that both parties agree to the terms and conditions. Primrose Villa DS0000026549.V268692.R01.S.doc Version 5.0 Page 8 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, 8, 9 Residents can be assured that changing needs are documented in their files; risk assessments are reviewed regularly; and there is frequent consultation with staff to ensure that residents are living their lives as they wish. EVIDENCE: Each resident has a number of folders ensuring that any changing needs are monitored and assessed. Two care plans were looked at in detail. Plans are duly revised and care reviews occur within the appropriate timescales. It was evident from the displays in the living areas that residents are consulted upon issues within the home, mainly through residents’ meetings. There are lists of ‘things we don’t like about our home’ and ‘what makes Primrose Villa a nice place to live’. The home is preparing for Christmas and lists of foods for the festive period are on display. Risk assessments with clear implementations are in place and are reviewed. A care plan and risk assessment is needed for the one resident who very occasionally smokes. Staff are aware of this. Primrose Villa DS0000026549.V268692.R01.S.doc Version 5.0 Page 9 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): 11, 12, 13, 14, 15, 16, 17 Residents benefit from being part of the local and wider community and are supported to maintain contact with family members and friends. Residents enjoy a healthy and nutritious diet. EVIDENCE: Residents enjoy a very lively life and participate in all sorts of activities inhouse and within the community such as bingo, pub meals, drama club, horse riding, and having parties for special events such as Halloween. Residents will be going to a Christmas Pantomime in the New Year. Another of Craegmoor’s homes is holding a Christmas Party where the residents will be able to choose whether to go or not. Some of the resident attend local day centres. One resident told the inspector about the college courses they had done and were doing, such as money skills and Spanish. Certificates on the wall further evidenced this. Each resident has a Key Worker who has more of an involvement in his or her care. Primrose Villa DS0000026549.V268692.R01.S.doc Version 5.0 Page 10 Residents are supported to maintain relationships with friends from previous residencies and family members. One resident meets up with their friends and goes into town, and the newest resident had the opportunity to visit friends and staff from their previous placement. This was evident in care plan notes and from talking with the residents and staff. Primrose Villa has recently introduced a new healthy eating 4-week menu planner. Staff and residents said that they are benefiting from this. Residents confirmed that they like the new menu are aware of their weight and are glad that they are losing weight. There are ‘lunch ideas’ in the kitchen to avoid residents just having a sandwich, such as baked potato with a healthy filling. Residents and staff eat together in the dining area, and it was observed how residents can eat at their own leisure at a time which suits them. Primrose Villa DS0000026549.V268692.R01.S.doc Version 5.0 Page 11 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): 18, 19, 20 Residents’ physical and emotional needs are met through the regularly reviewed plans ensuring that residents are supported at all times. Residents are protected by a robust medication system. EVIDENCE: The inspector saw that health and personal care needs are detailed with the necessary support required. Contact with the relevant professionals such as GP, optician, dentist, psychologist and chiropodist take place appropriately. The medication file was examined and was found to be well maintained. Local policies such as the safekeeping and administration and handling of medication was in place. Recording sheets were all signed. Risk assessments and details of the medication is kept within the personal files with much detail and information for staff. Two residents self-medicate and the deputy confirmed that they have the correct storage facilities. Staff also check with the residents that dosages and administration is correct. One resident takes the medication in front of staff to ensure that they do it correctly. One identified time for an administration needs to be changed via the pharmacy to ensure that the resident receives the medication at the correct time. This was discussed with the deputy. Primrose Villa DS0000026549.V268692.R01.S.doc Version 5.0 Page 12 Staff have to complete the one-day in-house training, then do a competency test which is followed by observations. The manager had recently given four members of staff a random competency test to ensure knowledge was at the best standard. Primrose Villa DS0000026549.V268692.R01.S.doc Version 5.0 Page 13 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, 23 Residents are protected from potential abuse and their views and concerns are listened to and acted upon. EVIDENCE: Staff have received Protection of Vulnerable Adults training. There are phone numbers displayed in two places for staff or residents to be able to report any malpractice (whistle blow) at any time. The inspector saw the complaints procedure and policy in pictorial format enabling all residents to understand the process. The two comments books in the hallway were read and are available for visitors and residents to write any concerns/compliments. Finance records for two residents were looked at. One record had a financial error. It is recommended that staff ensure that they document all monies within the paperwork within their weekly checks. This area will be re-visited at the next inspection. Primrose Villa DS0000026549.V268692.R01.S.doc Version 5.0 Page 14 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, 25, 26, 27, 28, 30 Residents enjoy a homely clean environment. Bedrooms are personal and there are sufficient toileting and bathing facilities meeting the needs of the residents. EVIDENCE: Primrose Villa has a homely and comfortable environment. During the tour of the property, some bedrooms were entered and all were found to be personally decorated and clean. One bedroom was being decorated on the day. Others have already had the interior updated, and there are plans for others to be redecorated in the New Year. There is one large lounge, with the Christmas tree, and an open plan dining and sitting area with the kitchen attached to it. There are pictures on the walls by the residents and a resident’s pet bird in the corner. There are French doors leading out to the garden and the barn. There are long-term plans to convert the barn into supported living quarters. Primrose Villa DS0000026549.V268692.R01.S.doc Version 5.0 Page 15 The kitchen is still in need of refurbishment due to it being old and having stained worktops. A new cooker is being fitted on 16/12/05 and the plan is to fit the kitchen in the New Year. The requirement remains. The recommendation from the previous inspection and noted from residents, a dishwasher would still benefit the home. There are 11 residents; therefore a lot of time is spent washing up. However, the kitchen was clean, tidy and free from dirty crockery. The identified bathroom from the previous inspection has been redecorated and is much more pleasant for the residents. There are sufficient toilet and bathing facilities for the number of residents living at the home. There is a pay phone in the hallway but is not is use. A resident confirmed that they have access to the home’s cordless phone and that staff do give privacy to the resident if they so wish. It was observed how residents could access all areas of the shared spaces. The staff sleep in room is located on the top floor, with phone access for emergencies. Primrose Villa DS0000026549.V268692.R01.S.doc Version 5.0 Page 16 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): 32, 33, 34, 35 Residents are well supported by a qualified and trained staff team. Staff are supervised to ensure that residents are well looked after. EVIDENCE: Training within the staff team is good. There is a statutory training matrix on the office door correlating with the training files so that it is clear when retraining is due. It was discussed that PoVA training dates should be added to the list. Staff also undertake ‘Non-Violent Crisis Intervention’; Appointed First Aid Persons; and ‘Equality and Reality’ training. The staff’s personnel files are kept in a locked cabinet and the manager is the sole key holder. Three new members of staff have recently been recruited. Some of their documentation was available to look at, except for their enhanced Criminal Records Bureau check. The deputy assured that their PoVA first checks had been returned and were in the cabinet, as the manager would not let them start until all checks were completed. The requirement from the previous inspection has been fulfilled regarding negative references. All new staff undergo supervised work for the first eight weeks. Again, supervision notes are held in the locked cabinet, but the deputy confirmed that she receives regular meaningful supervision. She is also being trained by the manager to be a supervisor. These standards will be a focus of the next inspection. Primrose Villa DS0000026549.V268692.R01.S.doc Version 5.0 Page 17 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): 37, 38, 40, 41, 42 Residents benefit from a stable staff team who work under the guidance of Craegmoor policies and procedures. The health, safety and welfare of the residents is promoted, however, staff require more frequent training regarding fire safety to ensure that all residents are kept safe. EVIDENCE: The inspector did not meet the manager during this visit but has had positive contact in the past. The manager has completed her Registered Managers Award and NVQ Level 4. The deputy was confident and knew the residents and staff well. She confirmed that she is always learning and used to work at the home some time ago. She has completed her NVQ Level 3 in care and has a wealth of experience and training such as ‘Recruitment Process’; ‘Equality and Reality’; and ‘Loss and Bereavement’. Primrose Villa operate an open door policy and the atmosphere is such that it is evident that residents are comfortable with asking and telling staff any such issue. Primrose Villa DS0000026549.V268692.R01.S.doc Version 5.0 Page 18 The deputy confirmed that there is a quality assurance system in place to gain views from the residents and their supporters. However, it is kept in the locked cabinet, which the manager is sole key holder. This will be a focus of the next inspection. Staff records are kept in the lockable cabinet to ensure confidentiality. Residents’ files are kept in the office for ease of access for staff and residents. Documentation is kept on site complying with legislation. Craegmoor supply each of their homes with a standardised set of policies and procedures. There are local procedures in place for issues such as medication. There has been a long-standing issue with staff smoking in the home. A policy must be implemented to ensure that everyone is clear regarding what is acceptable and what is not. The fire logbook was examined and the correct checks are carried out within the appropriate timescales. UK Fire recently visited the property and issued certain requirements for the home to do such as implement a smoking policy and to secure the papers on the pin boards. The food hygiene inspection report was carried out in January 2005. The generic fire risk assessment was reviewed in July 2005. Fire drills are carried out on a quarterly basis and there are also unannounced monthly drills. There is a record of staff’s fire safety training. At present this is on a yearly basis. It is required for staff to update their training on a 6 monthly basis for day staff and 3 monthly basis for night staff. As most staff do sleep-ins, training has to be on a 3 monthly basis. It is also recommended that there is a standard staff signatory list as some signatures are unidentifiable, and also some staff share the same initials to ensure correct accountability. Primrose Villa DS0000026549.V268692.R01.S.doc Version 5.0 Page 19 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 X X 2 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 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 2 X 2 X DS0000026549.V268692.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? YES 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 YA5 Regulation 5(c) Requirement Where relevant, residents to understand and sign their contracts. Timescale for action 31/01/06 2. YA24 23(2)(b)(c) Replace the kitchen cabinets etc, which are beyond repair and attend to the works highlighted by the Environmental Health Officer. (Previous timescale 01/09/05, enforcement action will be considered) 28/02/06 3. YA24 23(2)(b) Make safe the back step and consider adding a handrail. 28/02/06 (Previous timescale 01/08/05, enforcement action will be considered) 4. 5. YA40 YA42 13 (4)(c) 23 (d) Local smoking policy to be implemented. Staff to receive fire safety training on a 3-monthly basis. 31/01/06 31/01/06 Primrose Villa DS0000026549.V268692.R01.S.doc Version 5.0 Page 21 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. 3. 4. Refer to Standard YA6 YA23 YA24 YA41 Good Practice Recommendations Resident to have a care plan and risk assessment in place regarding their smoking. Staff to ensure that all balances of resident’s purses are correct. Purchase a dishwasher to improve health and safety requirements (recommendation remains). A standard staff signatory list is used to ensure accountability lines. Primrose Villa DS0000026549.V268692.R01.S.doc Version 5.0 Page 22 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 Primrose Villa DS0000026549.V268692.R01.S.doc Version 5.0 Page 23 - 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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