Inspection on 06/03/08 for Primrose Villa Rest Home

This inspection was carried out on 6th March 2008.

CSCI found this care home to be providing an Good service.

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 Rest Home 02/02/07

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Primrose Villa Rest Home 258 Preston Road Standish Wigan Greater Manchester WN6 0NY Lead Inspector Wesley Cornwell Unannounced Inspection 09:30 6 March 2008 th X10015.doc Version 1.40 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 Rest Home DS0000067897.V359635.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 Older People. 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 Rest Home DS0000067897.V359635.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Primrose Villa Rest Home Address 258 Preston Road Standish Wigan Greater Manchester WN6 0NY 01257 421737 01257 400003 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) Diamond Healthcare Limited Susan Burgess Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Primrose Villa Rest Home DS0000067897.V359635.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 15 service users to include *up to 15 service users in the category of OP (Old Age not falling within any other category). 2nd February 2007 Date of last inspection Brief Description of the Service: Primrose Villa Care Home is owned by Diamond Healthcare Ltd. The home is registered for 15 residents over the age of 65 years. The home is situated on the outskirts of Standish in Wigan and is close to local shops and amenities. The home has a garden to the rear and limited car parking at the side of the home or on the main road. The home is a two -storey building with bedrooms on both floors. There is a lounge and dining room on the first floor and toilets are close by. Bedrooms, bathrooms and toilets are situated on the first floor and are accessible by passenger lift. Accommodation consists thirteen single rooms and one shared room. One room on the ground floor has an en suite facility. The current scale of fees charged by the home is £362.00. Additional charges are made for hairdressing. Primrose Villa Rest Home DS0000067897.V359635.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This unannounced site visit was undertaken as part of the homes Key Inspection and commenced at 9.30am and took place over 4.5 hours. Prior to the site visit the manager of the home completed an Annual Quality Assurance Assessment form (AQAA) providing detailed information about the service they are providing. A number of people living at the home and their relatives were contacted prior to the site visit and their views about the home have been included in the report. In addition the Inspector spoke to five people, three staff members and the manager and deputy manager during the visit. Staff, care, maintenance and financial records were examined during the site visit and a full tour of the premises was undertaken with the manager and her deputy. What the service does well: The homes assessment and admission procedure are very thorough ensuring people that their needs will be met if they move into the home. One person said, “It was the best decision to move into Primrose Villa. The standards at the home are very high”. People seen during the visit said they liked living at the home and felt well cared for. One person said, “You will not get better care anywhere else. My friends are here and I am very happy”. The relative of one person said, “Very pleased with the caring attitude. The people working in the home seem to enjoy it”. People spoken to said they enjoyed the quality and variety of food being provided. One person said, “ We have a very good cook. All the meals are excellent”. Staff at the home have been well trained and are competent to do their jobs. Observation of care practices throughout the day confirmed people are treated with respect and dignity. The relative of one person said, “I feel the standard of care is excellent. The manager and her assistants are very approachable if I have any problems. The staff are excellent”. Primrose Villa Rest Home DS0000067897.V359635.R01.S.doc Version 5.2 Page 6 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 Villa Rest Home DS0000067897.V359635.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Primrose Villa Rest Home DS0000067897.V359635.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission and assessment procedures were clear to ensure the care needs of people are met. EVIDENCE: The care plan records of two people recently admitted to the home had full assessment information including their religious/cultural and relationship needs. The assessment had identified the nutritional needs of the people and risk assessment information advising staff members of the action to be taken to minimize identified risks and hazards. The staff members on duty confirmed they had access to this information and were fully aware of the care needs of the people living at the home. Primrose Villa Rest Home DS0000067897.V359635.R01.S.doc Version 5.2 Page 9 People spoken to during the visit confirmed they were happy with the care being provided and their needs were being met. One person commented, “You will not get better care anywhere else”. This home does not provide intermediate care. Primrose Villa Rest Home DS0000067897.V359635.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Promotion of health is taken seriously, people’s welfare is closely monitored and health needs were met. EVIDENCE: Individual records are kept for each person with a plan of care setting out the action that is needed to be taken by support staff to ensure all aspects of health, personal and social care needs of the people living at the home were met. Significant events had been recorded and daily entries made setting out the care given. The care plans were structured and were being reviewed with the people or their relative/advocate and updated to reflect any changing needs and these were being actioned as required. The records of two people were looked at and these described their healthcare needs. Discussion with staff members on duty confirmed they were fully aware of the healthcare needs of people living at the home and these are monitored Primrose Villa Rest Home DS0000067897.V359635.R01.S.doc Version 5.2 Page 11 and their care plans kept up to date. Entries made on care plans showed good communication between the home and healthcare professionals. The records of one resident confirmed a healthcare problem had been identified and appropriate action had been taken by the home to ensure the resident received the appropriate level of care. People spoken to said they liked living at the home and were well treated by staff members. One person said, “You couldn’t find a better home anywhere. The staff are all brilliant and cannot do enough for you. The standard of care is excellent”. The relative of one person said, “My mum is safe and well looked after”. Medication practices observed were safe and good records had been maintained. The staff members responsible for the administration of medicines had received accredited training to ensure they had basic knowledge of how medicines are used and how to recognise and deal with problems in use. People spoken to said the staff team respected their privacy and they could spend time on their own if that was their wish. Primrose Villa Rest Home DS0000067897.V359635.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities and meals are both well managed, creative and provide daily variation and interest for people living in the home. EVIDENCE: People spoken to said routines within the home were flexible and they were able to make their own decisions about how to live their lives. One person said, “You can come and go as you please. No one bothers you”. Another resident said, “It feels home from home and safe’”. People spoken to said they were happy with arrangements in place for receiving their visitors. The relative of one person commented, “Always made welcome whenever we visit. They make the home feel friendly and personal”. People spoken to confirmed they enjoyed the food provided by the home. The staff member responsible for the preparation of meals was able to confirm they had information about people with special diets and personal preferences. People spoken to were happy with the choice of meals available. One person Primrose Villa Rest Home DS0000067897.V359635.R01.S.doc Version 5.2 Page 13 said, “The food is very enjoyable. I am never left feeling hungry and the food is very tasty”. Meal times were served in a relaxed and unhurried manner. Staff members were observed being very attentive to the needs of people. People spoken to were very happy with the arrangements in place for social activities. These were varied and arranged individually and in groups. One person commented, “I enjoy the activities and like the singers that come into home”. Primrose Villa Rest Home DS0000067897.V359635.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for complaints are handled well and taken seriously ensuring people feel listened to. EVIDENCE: The home has a detailed complaints procedure, which is made available to everyone on their admission and is also on display for the attention of all visitors. People spoken to were aware of how to make a complaint and felt these would be listened to and acted upon. The relative of one person said, “Any complaints or issues I have regarding mum’s care are dealt with immediately by management’”. At the time of this site visit no complaints had been referred to the home or the Commission for Social Care Inspection. The home has a procedure in place for dealing with allegations of abuse. All staff have received training in the protection of vulnerable adults and showed a good understanding of the procedures to be followed in the event of any allegations or suspicion of abuse or neglect. Staff members spoken to said they wouldn’t hesitate to report any concerns they had about care practices to ensure people living at the home are protected from potential harm or abuse. Primrose Villa Rest Home DS0000067897.V359635.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a planned maintenance and renewal programme for the redecoration and refurbishment of the home to ensure people live in a comfortable, homely, clean and safe environment. EVIDENCE: The home has been well maintained and decorated for the comfort of people living there. Since the last inspection the owners have continued with their refurbishment programme with a number of rooms being decorated and a bathroom on the first floor being refurbished. The manager said the refurbishment of the home was ongoing. People spoken to were very happy with the improvements being made. Primrose Villa Rest Home DS0000067897.V359635.R01.S.doc Version 5.2 Page 16 A tour of the building confirmed people had personalised their bedrooms with their own belongings. People spoken to were happy with their rooms and said they had the choice of spending time on their own or in the lounge area’s. Hot water temperatures throughout the home were checked and found to deliver water at a safe temperature in line with health and safety guidelines. It was observed during the visit the home was clean and hygienic ensuring a pleasant environment in which to live. Primrose Villa Rest Home DS0000067897.V359635.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The deployment of a well-trained staff team throughout the day is sufficient to meet the needs of people living at the home. EVIDENCE: Staffing levels were sufficient for the number of people living at the home. People spoken to said they were happy with the care they were receiving and were well treated by the staff. One person said, “Everyone is so kind, the care is excellent”. The relative of one person said, “‘My mum is safe and well looked after. She is always clean, well groomed and her bedroom always looks nice”. Staff spoken to said they were clear about their role and work well as a team to ensure the individual and collective needs of residents are met. Records show all staff members have access to a structured training and development programme ensuring the residents are being cared for by a well trained and competent staff team. In addition 84 of staff members have achieved National Vocational Qualifications (NVQ) ensuring the residents are in the safe hands of qualified and competent staff. Primrose Villa Rest Home DS0000067897.V359635.R01.S.doc Version 5.2 Page 18 Examination of staff records showed good systems were in place for obtaining relevant documentation for staff members employed by the home ensuring the protection of the people living there. However, there was some discussion with the manager about written evidence being available confirming Protection of Vulnerable Adults (POVA) checks have been made before staff members have commenced their employment. The homes recruitment procedures should be reviewed to ensure this information is clear. Primrose Villa Rest Home DS0000067897.V359635.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run and has policies and procedures in place to ensure the health and safety of staff and people living there are promoted and protected. EVIDENCE: The manager has many years experience in caring for the elderly and has relevant management and care qualifications. She is well supported by the homes owners who visit the home regularly. Records seen confirmed the manager has access to training to ensure her knowledge and skills are updated. Primrose Villa Rest Home DS0000067897.V359635.R01.S.doc Version 5.2 Page 20 The home has effective quality assurance systems in place to monitor the level of service being provided for people who live there. An annual quality assessment of standards has recently been undertaken by a professionally recognised organisation who completed an audit of the care being provided and also sought the views of people living in the home and their relatives. In addition the home has in place its own quality assurance systems to gather the views of people and keep them informed about events being organised by the home. People spoken to confirmed they are consulted about changes taking place in the home and were well informed about events being organised. Financial records were well maintained and up to date ensuring the interests of people are safeguarded. Inspection of maintenance records confirmed facilities and equipment was being maintained as required by health and safety legislation to provide a safe environment for people and staff. Primrose Villa Rest Home DS0000067897.V359635.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Primrose Villa Rest Home DS0000067897.V359635.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action 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 OP19 Good Practice Recommendations The owners should continue with the homes programme for the decoration and refurbishment of the premises to ensure people live in a well-maintained and comfortable environment. Employment records should show clearly that staff members have not commenced their employment until their Protection of Vulnerable Adults (POVA) clearance has been received ensuring the protection of people who live in the home. 2. OP29 Primrose Villa Rest Home DS0000067897.V359635.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Villa Rest Home DS0000067897.V359635.R01.S.doc Version 5.2 Page 24 - 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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