Care Home: Primrose Villa

Similar services:

• 32 Beaumont Way
• 2 Perhaver Park
• The Vicarage
• St George`s
• 5 Seafield Road
• Radfords
• Honeybourne House

What the care home does well Primrose Villa is a very homely home with a vibrant and busy atmosphere. There is a lot of positive interaction between residents, and residents with staff. A relative`s survey in the home stated that "know that ** is well looked after. We thank-you all for that". Residents are fully involved with their care and the development of the home. Residents are supported to make informed decisions about their lives and their daily routines are totally respected. Residents choose how they live their lives. Records within the home are very well kept; well written, and kept up-to-date. Staff are well trained and refresher courses are booked accordingly. The manager supports and supervises the team very well and provides good leadership and clear direction. Residents are supported to raise complaints they have and are comfortable with approaching staff. Systems are in place so that residents are protected from all forms of abuse and are kept safe within and outside their home. Residents live in a very well managed home. What has improved since the last inspection? There has been improvements within the environment of the home such as a re-decorated bathroom and upgraded hob in the kitchen. The lounge has also been re-decorated. Residents` care notes have been transferred over to the company`s new person centred document and the new Health Action Plans are being developed at the moment. What the care home could do better: As stated in the AQAA and as discussed with the manager, there has been a relatively high staff turnover. The manager has negotiated within the home`s budget a rise in pay which could help retain staff and provide residents with a more consistent staff team. The side lane next to the home needs to be re-surfaced. It has been a longstanding problem and the maintenance team has started the initial planning of it. It is hoped that this will be completed in the near future to ensure residents` safety. CARE HOME ADULTS 18-65 Primrose Villa 250 Fishponds Road Upper Eastville Bristol BS5 6PX Lead Inspector Nicky Grayburn Key Unannounced Inspection 9th October 2007 10:30 Primrose Villa DS0000026549.V351039.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 Villa DS0000026549.V351039.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 Villa DS0000026549.V351039.R01.S.doc Version 5.2 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 www.craegmoor.co.uk Parkcare Homes Ltd 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) 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.V351039.R01.S.doc Version 5.2 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 31st October 2006 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. The range of fees is from £496.13 to £904.17; dependent upon the resident’s assessed needs. Prospective residents can be provided with information about the home and this will detail the services and facilities available. Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was Primrose Villa’s key inspection. The visit was unannounced and lasted one day. The inspector met with many of the residents and staff, including the Manager. There were no requirements to follow up from the previous visit. Prior to the inspection, previous records and reports held at the Commission for Social Care Inspection were read, such as the home’s monthly reports carried out mainly Craegmoor’s Area Manager or another home manager. The Manager also completed the Commission’s ‘Annual Quality Assurance Assessment’ (AQAA) giving information regarding the service including details relating to each of the headings below. The inspector looked at key documents; talked with and observed residents, staff and the Manager on a one-to-one basis; and undertook a tour of the property. Surveys were sent out to the home and the manager said that she had sent them on and some residents had completed them. However, none were received by the Commission for Social Care Inspection. The inspector read the 5 relatives’ surveys which had recently been completed for the home. Some of the findings are included in this report. 2 residents were case tracked and the inspector spot-checked other residents’ records. Verbal feedback was given at the end of the inspection to the Registered Manager. A further phone call was held with the manager to clarify certain matters. What the service does well: Primrose Villa is a very homely home with a vibrant and busy atmosphere. There is a lot of positive interaction between residents, and residents with staff. A relative’s survey in the home stated that “know that ** is well looked after. We thank-you all for that”. Residents are fully involved with their care and the development of the home. Residents are supported to make informed decisions about their lives and their daily routines are totally respected. Residents choose how they live their lives. Records within the home are very well kept; well written, and kept up-to-date. Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 Page 6 Staff are well trained and refresher courses are booked accordingly. The manager supports and supervises the team very well and provides good leadership and clear direction. Residents are supported to raise complaints they have and are comfortable with approaching staff. Systems are in place so that residents are protected from all forms of abuse and are kept safe within and outside their home. Residents live in a very well managed home. 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 DS0000026549.V351039.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, 5 People who use the service experience good quality outcomes in this area. The Statement of Purpose and Service User Guide give residents good information about the home. Potential residents would have the opportunity to test drive the home prior to moving in to ensure that it’s the right home for them. Residents have written agreements about living in their home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is currently updating the home’s Statement of Purpose and Service User Guide due to staffing changes. It was agreed that she will be sending the Commission for Social Care Inspection a copy of the updated versions once completed. The Annual Quality Assurance Assessment (AQAA) stated and it was seen by the inspector that the Service User Guide also contains pictures to aid those residents who may have difficulties in reading such a document. The home is registered for 8 residents; 7 residents live in the home at present. The AQAA states that the home does not accept any residents in an emergency situation. The vacancy at the moment is in the shared room and the manager confirmed that unless the resident wanted to move rooms and a couple wanted to move in, it is not feasible to have full capacity in the home. Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 Page 9 There have not been any new residents moving into the home since 2005. The AQAA and Statement of Purpose states that prior to moving in, the potential resident would be given as much information as possible and visit at least 4-5 times, then stay overnight to ensure that it was where the resident would like to live. Residents have copies of their contract and terms and conditions in their files which they can access at any time. Contracts from the resident’s funding authority reflect current fees. Those contracts seen between the home and resident were signed by the resident and include the complaints procedure and the service user guide, but dated from 2003. The manager confirmed that these will be updated and include the house rules. The house rules are being translated into symbols for residents to understand them more easily. Whilst speaking and observing residents, it is clear that residents are fully aware of what is expected of them. When necessary, some residents have had temporary agreements in place to ensure that they and others remain safe. As detailed in the rest of this report, residents have care plans in place reflecting their current needs and are reviewed regularly by staff and the manager. Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 People who use the service experience excellent quality outcomes in this area. Residents know that their individual support plan is based on their views and is there to support their needs and choices. Residents make informed decisions about their lives and are encouraged to participate in most aspects of life in their home. Residents know what is written about them and that the information is respected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each resident has a wealth of information about their life, which staff can access in order to support the resident. Residents have support plans in place written in a person centred approach. The format is in plain language and has pictures to help the resident understand. Entries are written with the resident, or residents sit with the staff member and are told what is written and then they can sign to state whether they agree with it or not. Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 Page 11 It was clear from the visit; previous visits; talking with residents; and reading care notes that residents are fully involved with their care in their home. New staff members told the inspector how easy it was to read the care plans and understand the residents’ needs. There are documents entitled ‘Things that make me happy’, ‘Things that I like’; ‘Things that make me sad’; ‘Things that make me angry’ for staff to read and have an understanding of the resident prior to working with them. Specific support plans are written when residents display behaviour that can be challenging to others or may harm themselves. Residents told the inspector about these and understand why they are in place. All support plans are reviewed regularly and, with permission of the resident, family members are invited to the reviews. Each resident has a key worker. Key workers write monthly ‘updates’ to ensure that care needs are being met, and spend 1:1 time with the resident. Residents have recorded ‘What I do now’ and ‘What I’d like to do’ reflecting their goals and aspirations. These correspond to the residents’ daily activities. Most residents have active supporters they can talk with if they have any concerns and can act as their advocate. The inspector spoke with a resident and the manager about this and the manager has sourced local advocacy groups if residents wish to contact them. The AQAA stated, and the inspector viewed some ‘easy read information sheets’, which the manager has developed for residents to ensure that they can make an informed decision about areas in their lives. These sheets are also used for discussing issues (i.e. bullying, racism, advocacy), which could arise in the home. This is good practice. There is also a ‘Resident of the Month’ award for those residents who have done things like helping the staff and keeping their room clean and tidy. The home also has annual awards for all residents for things that they have achieved over the year. As stated throughout this report, residents participate in aspects of the home, for example, in the interviews of staff; carrying out Health and Safety checks; attend training sessions; suggest activities, and complete quality assurance questionnaires. Some residents also attend the organisation’s ‘Resident’s Forum’ which is a regional meeting for residents. The AQAA stated, and the inspector read the risk assessments in place, “not to disempower people but to enable people to take reasonable risks whilst keeping safe”. Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 Page 12 A monthly report from the home and the resident’s meeting minutes informed the inspector that residents were asked what they thought a risk is and staff explained why these assessments are in place. Assessments are reviewed monthly and updated accordingly. New assessments are written as and when necessary. At the front of the care plan, residents have signed a form to state whether they agree for the information about them to be shared with others, for example other professionals and inspectors. It is clear from documents that residents are asked whether they wish their family to be informed of information. Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 Page 13 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, 12, 13, 14, 15, 16, 17 People who use the service experience good quality outcomes in this area. Residents have a lifestyle and daily routine, which they enjoy and suits their needs and preference. Residents are able to participate in their local community and leisure activities. Residents are supported to maintain their relationships with their friends and family. Residents are offered a healthy diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was evident from the visit, observing residents, reading records and from what residents and staff told the inspector that residents enjoy their lifestyle in their home. The home organises events within and outside the home, for example a Halloween party; a sponsored walk for charity, and meals out. It was observed how the residents get involved and have ideas for future events. There is a discreet weekly activities programme to make sure that residents’ needs and goals are achieved. This is linked into their care plan. Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 Page 14 Some residents go to local colleges and day centres. Residents told the inspector about the courses they are doing, and certificates on display show how much the residents do and are praised and commended for. Some the residents told the inspector about their attendance of some training, such as Food Hygiene, Fire Safety, and First Aid. It was observed on this visit, and during previous visits, that residents have their own routines and this is respected. Most residents can come and go from their home as they wish and there is no curfew time to return. It was observed that there was enough staff to support those residents who require more support when going out into the community. Some residents have their own key to their bedroom and their front door. This is duly recorded in their care plans, and it was observed how it was discussed with one resident. It was also observed how residents could get up, get dressed, and eat when they wish. Residents’ preferred name is recorded and used. It was observed that residents have unrestricted access to all the shared areas and can choose when they want to be alone or with others. Within residents’ care notes, people who are important to them are detailed. Some residents had visited family members during the visit and residents told the inspector about their friends and family. Time is designated for residents to contact their supporters. The questionnaire sent out to relatives asked, with resident’s permission, if they would like to be sent ‘updates’ on their relative. Staff are aware of the relationships which residents would like to develop and are supportive of this, and are aware of the impact of their presence when going out. Most residents go on holidays with support from staff, some choose not to go which they told the inspector about. Some went to a holiday centre; some are going to Spain, and some went to the southern coast. One of the residents explained the menu and showed the inspector round the kitchen. There is a menu on display, which is used as a guide, shows a balanced and healthy diet. It was observed how residents are asked if they would like any lunch/dinner, then if they would like what is being cooked, then if not, what they would like. Hot food temperatures are recorded. Residents had different meals according to their preference and was served in an unhurried and relaxed way. Residents also have cooking and washing up days. It was also observed and read in notes how residents help to buy the food and prepare the mealtime. A recent resident’s meeting also discussed the menu for the future and residents gave suggestions. Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 Page 15 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 People who use the service experience excellent quality outcomes in this area. Residents receive personal support in a way they prefer and wish. Residents can be assured that their physical and emotional needs are and will be met with support from staff. Residents are protected by the medication system. Residents can be assured that their wishes if they become very ill or die will be respected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Details of residents’ health needs are recorded in their notes. At present, staff are transferring information to the new Health Action Plans which covers all areas of the residents health. The current notes are good and written with a person centred approach, and gave the inspector a full picture of the residents’ needs. Personal care needs are recorded in the residents care plans and details how the resident needs support or prompts. There is detail such as wishing to have bubble bath; what flavour toothpaste and how to support them with getting dressed. It was observed how residents are treated with respect and dignity. Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 Page 16 Sensitive issues are discussed in private and residents are also reminded of this. Residents are supported to access local health professionals such as the dentist, optician, audiologist, and chiropodist. These appointments are recorded in residents’ notes to ensure that follow up and regular appointments are kept. Some residents refuse to see some professionals such as the dentist. This is recorded and residents told the inspector about this. Residents receive the annual flu jab. It was observed, read in notes, and staff told the inspector that changes in residents’ health, both physical and emotional, are observed by staff and other times, residents approach staff with any concerns they have. Specialist intervention is sought as and when necessary, for example from the Community Learning Difficulties Team and Psychiatry. It was evident that residents wore clothes which reflected their personality. Preferred clothing is also recorded in the residents’ care plans. The medication system was inspected with the manager. Some residents are able to look after their own medication and are supported to do so. There are no controlled drugs administered to residents. The Medication Administration Records were signed by staff to state that the medicines had been administered. There is a corresponding signatory list of staff signatures. The Commission for Social Care Inspection has not received any notifications of errors. The home has recently moved to the Monitored Dosage System, which the manager said was a lot easier. The manager has a training pack for staff to do to ensure that the new system is fully understood. The inspector saw in staff’s files that some staff have already undertaken the training with the pharmacy. From the files read, residents have been asked about their wishes if they were to get very ill or die. Details have been recorded so that staff are aware of what the resident wishes. This is good practice. Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 Page 17 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 People who use the service experience good quality outcomes in this area. Residents are comfortable with raising concerns with staff and they will be listened to. Residents are protected from abuse, neglect and self-harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints log was read and is being updated with the organisation’s new paperwork. The inspector read the last few complaints and the responses made by residents to external parties. The resident’s meetings minutes evidence that it is a subject which is brought up regularly. In a recent meeting, residents were asked who they would speak to and most residents said that they would speak to a member of staff or the manager. The relative’s surveys, for the home, confirmed that they knew how to make a complaint. The complaints procedure and policy are in a format which residents may find easier to understand. The recording form is a generic corporate version. This was discussed with the manager who told the inspector that the residents would need support from staff to complete any form and that in the past, residents tell staff their problem and the staff write it out with them. The manger stated that she has a new programme to translate documents into symbols which she will be using in the near future and will be re-doing a complaints form to promote residents’ independence. It was observed during the visit how residents appeared confident and comfortable with raising issues with members of staff and especially the manager. Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 Page 18 Staff receive training in the Protection of Vulnerable Adults within their induction period and have annual refresher courses. The training is either carried out by an internal trainer or by Bristol City Council’s Adult Community Care department. The Commission for Social Care Inspection has not received any notifications or referrals regarding any abuse against any of the residents. Any disagreements between residents are recorded and staff intervene appropriately. A resident told the inspector about one incident and how it was dealt with. Staff also undertake a 1-day training in Non-violent Crisis Intervention to ensure that they know how to manage any incidents correctly. The home operates a ‘No Restraint’ policy. Residents who have tendencies to self-harm are supported to overcome difficulties. This is recorded in their care plans and the manager explained the strategies staff use to ensure the residents remain safe. From the records seen, residents have a personal belongings list to ensure that there is a record of what is theirs to protect the resident. It was clear that this is updated regularly. Most residents look after their daily monies. The home does not hold any money for the residents. The manager explained their new system. If residents want any money, they ask the staff, the staff take it from the petty cash amount and then put it through the system on the computer which head office calculates. The resident then receives a statement detailing their expenses. The manager said that it was a lot easier now. This system may be safer for the residents as there are no large amounts of money held in the home for individuals. Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 Page 19 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, 26, 27, 28, 30 People who use the service experience good quality outcomes in this area Residents live in a homely, clean environment with large shared spaces and personalised rooms. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector undertook a tour of the home with a resident. Primrose Villa is a large property with spacious shared rooms on the ground floor. The main room is an open plan dining and lounge area which the kitchen and office are attached to. It has a homely vibrant atmosphere. A resident had recently helped the maintenance man to re-decorate the room and there are photos of the residents and achieved certificates on display which residents proudly showed the inspector. There is also a main large lounge which some residents prefer to use to relax in. The inspector was invited to view 2 bedrooms which were both very personalised with pictures, certificates and personal effects. Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 Page 20 Residents also pointed out new furniture and how they had tailored their room to their tastes and needs. There are 3 toilets in the house for residents and 1 for staff’s use on the ground floor. There is 1 shower room and 1 bathroom. This is detailed in the home’s statement of purpose and was discussed with the manager. Residents have sinks in their bedrooms. Despite the National Minimum Standard stating that there should be no more than 3 residents per bathroom, there have not been any issues with this situation since the home opened. Consideration would have to be given if this changes. The home operates a no-smoking policy. There is a tidy front and rear garden which is used in the warmer months. Primrose Villa also has a barn and garage building at the end of the garden. This has been a long standing project to renovate it into a supported living project but due to foreseeable costs, it has not been carried out. However, the manager told the inspector that plans have been re-started. This would be a good ‘stepping stone’ for those residents who could have a more independent lifestyle. There is a laundry room with sufficient facilities for the residents. Cleaning products are kept in here and some residents have access to certain products. Staff are provided with a ‘sleep-in’ room on the top floor. There is a lane next to the home which is used to access vehicles when going out. There are many potholes, which pose a safety risk and the surface is unsuitable for residents with mobility difficulties. This has been a long-standing issue as it is not specifically the home’s property. The manager informed the inspector that the process for re-surfacing it has begun. It would be beneficial for all if this is completed in the near future. The relatives surveys had all ticked the excellent or good option relating to the question about the home being clean, homely and well furnished. On the day of inspection, the home was clean and there were no offensive odours. Staff are trained in Infection Control. Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 Page 21 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): 32, 33, 34, 35, 36 People who use the service experience good quality outcomes in this area. Residents are supported by a motivated and trained team of staff. Residents benefit from a very supported and supervised team. Good recruitment practices protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector met with and observed a number of staff during the visit. The manager confirmed that there is a full compliment of staff at present. When residents are in need of more 1:1 time, staffing levels are reviewed and changes are made accordingly. There have been a few staff who have left in the past 12 months and these vacancies have been filled. Staff spoken with told the inspector about their induction period and how they are reading about the residents’ needs. They appeared motivated and have relevant previous experience. The manager showed the inspector the file staff have to complete to ensure that they understand the residents’ needs and how the home and organisation operates. Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 Page 22 There are some members of staff who have worked for a number of years at the home. Their responsibilities are being increased with supervision from the manager. A comment in a relative’s questionnaire was “There was a great rapport between the staff and residents which is found to be most encouraging.” This rapport was observed on this visit, and on previous visits. Residents told the inspector that the “staff are alright” and “yeah, they’re really nice”. It was noted that all staff use the residents’ preferred names and responded well to residents’ requests. Interaction between residents and staff was positive and proactive. 5 staffing records were inspected and the relevant documentation was in place, such as a completed application form; 2 satisfactory references; and Enhanced Criminal Record Bureau checks. It was recorded and residents told the inspector about how they are involved in the interview process, which is good practice. It was discussed with the manager how gaps in application forms must be explored during the interview process. Training needs of the staff team is monitored by the manager and by the staff themselves. Completed training is recorded is individual’s files and on a format which is clear to understand. Some staff are in need of refresher courses and the manager showed the inspector on the staff rota, that an external trainer, employed by Craegmoor, is coming to the home for a week to ensure that all the training is up-to-date. All staff complete the Appointed First Aid training, which is good practice. Due to some of the residents’ needs, additional training to the mandatory training is undertaken, such as Autism and Dementia to ensure that staff are fully aware of the residents’ needs. The AQAA stated that 3 of the 7 staff team have their National Vocational Qualification. Staff meetings are held on a monthly basis, and the minutes were read by the inspector. It was clear that residents’ changing needs are discussed and actioned by the team. The home has an ‘Employee of the Month’ scheme which has been operating for a while which induces motivation and encouragement. Residents are hugely involved in this. Supervision records were read and evidenced that these meetings are regular. The organisation provides the staff with Personal Performance Agreements, which allow for an efficient annual appraisal and ensure that all areas of their role in the home and organisation are covered. The manager also has a more personalised version to ensure that staff feel fully supported. The newer members of staff confirmed that they do feel fully supported by the staff team and the manager. Copies of the grievance and disciplinary policies can be found in the office, which is accessible to staff at all times. Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 Page 23 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, 39, 41, 42, 43 People who use the service experience excellent quality outcomes in this area. Residents live in a very well run home. Residents’ health and safety is promoted, therefore residents are protected. Residents can be assured that their views and other quality assurance systems in place underpin the development of the home. Records are effective and well maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of Primrose Villa was present and available to the inspector throughout the visit. Ms Clay has been the manager at the home for a number of years and is competent, confident and comfortable in her role. Due to restructuring of another home, Ms Clay will be also managing another home in the near future. Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 Page 24 The Commission for Social Care Inspection has been informed throughout this process and has no reservations regarding this decision or of Ms Clay’s ability to do this. Ms Clay will be applying for the registration shortly. However, as discussed with Ms Clay, it is imperative that there are strong senior support workers or deputies in place to ensure that the homes continue to run smoothly and that residents remain safe; and also that she receives good support from her line manager. During the visit, and on previous visits, it has been observed that there is an open and positive atmosphere in the home. The manager provides clear leadership and support, and is available to both residents and staff. The manager gives praise and constructive guidance to staff through staff meetings; supervisions, and on a daily basis. The AQAA stated that there is a 3-year business plan in place. The manger spoke coherently about the budget and the financial constraints and abilities of the home. There are no requirements from this inspection. Previously Ms Clay has complied fully with the regulations, and continues to do so to ensure that residents are safe, protected, and have a life they choose in their home. The insurance cover in place ensures that the home is fully insured to meet any loss or legal liabilities. The home has a quality assurance file in place which holds all the necessary documents to be able to reflect on the home’s development. The organisation carries out various internal audits covering finances; care services; infection control; medication; Health and Safety, and an overview. As stated earlier in the report, the home holds regular residents’ meetings; staff meetings; staff supervisions, and also sends out questionnaires to relatives of the residents to gain their views on the home. The Area Manager or a manager from another of Craegmoor’s homes visits the home monthly to check on the home including talk with residents; staff; and the premises. It was discussed with the manager that once the results from the questionnaires from relatives and residents, the results are to be sent to the inspector. It was observed how new staff members read and sign policies and procedures which are new to the home from head office. The organisation sends out new and/or reviewed policies to the manager to cascade to the staff group. Standard 40 was not fully inspected. Records in the home are well organised and up-to-date. Residents are aware of the records kept about them. It was observed how residents are told when a significant entry has been made and what it says, and most documents, where appropriate, have been signed by the resident. As written under Standard 6, whilst speaking with some new members of staff about their induction, they told the inspector about the quality of the records held and how it was easy to locate information. Records are kept either in the office, which is locked when staff are not present, or in a lockable cabinet in the dining area. Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 Page 25 The health and safety, and fire folder was inspected and corresponds to the detail given in the AQAA. The home ensures that relevant checks and inspections from external inspection bodies take place regularly. Staff in the home carry out internal checks on fire fighting equipment and is duly recorded. One resident has specific responsibilities ensuring that food is safely stored in the fridge and freezer, and reports back to the manager. Temperatures of the fridges and freezers are recorded daily. Maintenance of the home is upheld. Issues are recorded, reported and acted upon effectively. Residents told the inspector about the fire procedure, and records were seen regarding fire drills. These happen monthly and are ‘unannounced’. Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 Page 26 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 1 2 3 4 5 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 4 4 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 4 4 3 X 4 3 3 Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 Page 27 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. Refer to Standard Good Practice Recommendations Primrose Villa DS0000026549.V351039.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 DS0000026549.V351039.R01.S.doc Version 5.2 Page 29 - 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!