Inspection on 17/05/05 for Carlton Villas

This inspection was carried out on 17th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 but made no statutory requirements on the home.

Other inspections for this house

Carlton Villas 31/10/07

Carlton Villas 07/03/07

Carlton Villas 21/10/05

Carlton Villas 07/12/04

Carlton Villas 05/08/04

Carlton Villas 17/02/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Carlton Villas 2 Pelham Road Undercliffe Bradford BD3 3DB Lead Inspector Michael Smithson Unannounced 10.30am 17 May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Carlton Villas J52 S1303 Carlton Villas V226810 170505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Carlton Villas Address 2 Pelham Road, Undercliffe, Bradford, West Yorkshire BD2 3DB Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01274 634913 Mr John Thomas Lamb Miss Victoria Hargreaves (Post now vacant) Care home only 13 Category(ies) of Old age (9), Dementia over 65 (2), Physical registration, with number disability over 65 (2) of places Carlton Villas J52 S1303 Carlton Villas V226810 170505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7 December 2004 Brief Description of the Service: Carlton Villa is a detached adapted property with a small extension to the rear. The home provides accommodation for 13 service users in nine single and two double bedrooms, two of which have en-suite facilities. The home is close to a good range of local amenities including shops, public houses, a library and a park. The home is also well served by local transport. Carlton Villa provides a service for users who require general personal care which is not nursing. A small number of special categories can be accommodated however the care provided must be manageable within a personal care setting. There is good disabled access into the premises and a car park is provided to the front of the building. There is a large conservatory available and a pleasant garden. Carlton Villas J52 S1303 Carlton Villas V226810 170505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was an unannounced inspection and took place over the morning and early afternoon of the 17th May 2005. The inspection focused on the issues outstanding from the last inspection, records, discussions with staff and service users. Since the last inspection the management of the home has changed. The registered manager has now left and the deputy manager has taken on the responsibilities and is being put forward for registration. The change has caused some disruption to the home, however the proposed manager is clear as to the work required to maintain and improve standards. A number of the requirements and recommendations highlighted at the last inspection had not been undertaken. The proposed manager was aware of what now needs to be completed. What the service does well: What has improved since the last inspection? The home has undergone a difficult period with the registered manager being on sick leave for a long period of time and having now left the home. The issues highlighted at the last inspection had not been actioned. This has meant Carlton Villas J52 S1303 Carlton Villas V226810 170505 Stage 4.doc Version 1.30 Page 6 there has been little improvements made since the last inspection. However the care provided has been maintained to a good standard. 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. Carlton Villas J52 S1303 Carlton Villas V226810 170505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Carlton Villas J52 S1303 Carlton Villas V226810 170505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2,3,4 and 5. Improvements are required to the information available to service users, relatives and placing agents. The pre-admission procedure needs to be improved to determine that appropriate placements are admitted to the home. EVIDENCE: During discussions with the propsed manager it was evident they do offer service users a choice of suitability of placement and information regarding Carlton Villa. However evidence that this occurs is difficult to locate in the records kept at the home. The new statement of purpose and service users guide are still outstanding from previous inspections, however the proposed manager has taken onboard the need to make the service user guide more user friendly. A draft copy will be provided for CSCI prior to the final version being agreed. At the last inspection a requirement was made to alter Section 8 which refers to medication and the change needed giving the service user the choice to self medicate if they are able and wish to do so. This is being addressed by the proposed manager. Carlton Villas J52 S1303 Carlton Villas V226810 170505 Stage 4.doc Version 1.30 Page 9 The service user records show that a pre-admission assessment has not been completed for all service users. This was also highlighted at the last inspection. It was noted that a format is available but is not used for new admissions. Written evidence is still needed to show how service users are admitted to the home and whether introductory visits and trial stays are provided. This information should be recorded in individual service user files. Carlton Villas J52 S1303 Carlton Villas V226810 170505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 9. The care records do not always reflect the needs of service users. EVIDENCE: The records for 3 service users were checked. The information held is often repetitive, with differing formats used in different records to record the same information. This leads to a lack of consistent recording of information and makes it difficult for staff to know where to up date the records. Pre-admission information was lacking, which would have given staff basic information to prioritise details recorded in the care plans. No agreed timescale and procedure was available to review the care plans. The care plans did often include information which would normally be recorded in the daily reports, which appears to dilute the information which was important to individuals care. The proposed manager was aware of some of the short falls noted in the care records at both this and the last inspection. To address this she is implementing a new key worker system which identifies the staff responsibilities for record keeping. She also agreed to look at producing a Carlton Villas J52 S1303 Carlton Villas V226810 170505 Stage 4.doc Version 1.30 Page 11 more effective care planning system which is more focused to the needs of the service users and is less repetitive. The care records must include health care assessments for service users, in particular, pressure care, manual handling, falls and nutrition. Other needs noted which are relevant to the wellbeing and safety of service users must be included in individual risk assessments. A photograph of each service user is still required from previous inspections. Carlton Villas J52 S1303 Carlton Villas V226810 170505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 14 and 15. Carlton Villa provides a range of activities geared to both individuals and small groups EVIDENCE: During discussion with service users it was noted that they do have the opportunity to engage in some activities, these tend to be videos and sing a longs. The staff did spend time with service users chatting and carrying out basic personal care tasks. One service users attends a local day centre 1 day a week. The proposed manager is hoping to develop the range of activities offered and hopes to organise topical events such as VE Day celebrations and an outing. The menus were discussed with a number of service users and positive comments were made regarding the food provided, however it was felt they were now in need of a change. The manager has already had discussions with the cook regarding planning new menus. Carlton Villas J52 S1303 Carlton Villas V226810 170505 Stage 4.doc Version 1.30 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 14. A robust adult protection and complaints policy and procedure ensures that service users are listened to and are protected from abuse. EVIDENCE: A complaints policy and procedure has been produced for the home. It will be included in the new service user guide being produced by the manager. No new complaints had been made since the last inspection. Service users were given the opportunity to vote in the recent general election. This tended to be by postal votes. An adult protection policy and procedure has been produced. The local authority No Secrets guidance is also available. The staff have undertaken some basic training regarding adult protection. The manager is also booking onto the local authorities own training course. This is good practice. Carlton Villas J52 S1303 Carlton Villas V226810 170505 Stage 4.doc Version 1.30 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) An inspection of the building was not undertaken during this visit. EVIDENCE: Carlton Villas J52 S1303 Carlton Villas V226810 170505 Stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30. The staffing levels were adequate to meet the needs of the service users. The staffing levels have remained stable. A very good level of training has been provided to ensure staff had appropriate skills to meet their needs. EVIDENCE: There are no staff vacancies at the home. No new staff have been employed since the last inspection. The staffing has remained stable with no changes to the care staff since the last inspection. This does help to provide consistency of care for service users. Eight of the staff team have now completed NVQ 2 and one is due to start the training. This means the home has exceeded the required 50 NVQ 2 qualified care staff. Good levels of training have been provided for the staff team including the basic core training. Specialist training regarding infection control is being organised to provide additional expertise to cope with the needs of a service user living at the home. The manager has recently completed a course enabling her to provide the staff with manual handling training. Discussions took place with staff. They were aware of the changes at the home with regard to the registered manager. They felt that the change had caused some up set, however the care provided to service users on a daily basis had Carlton Villas J52 S1303 Carlton Villas V226810 170505 Stage 4.doc Version 1.30 Page 16 not been effected. Some service users had known the registered manager a number of years and did require support and reassurance from the staff team. Carlton Villas J52 S1303 Carlton Villas V226810 170505 Stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 36, 37 and 38. The recent management changes has caused some disruption, however the levels of care provided on a daily basis has not been greatly affected. EVIDENCE: There has been a change to the management of the home. The registered manager has now left and is being replaced by the deputy manager who has applied for registration. The staff are aware of the changes and a staff meeting has been arranged to provide further information. A programme of individual supervision and appraisal is being discussed, however it was agreed it would not be seen as a priority at this stage. The new proposed manager has taken onboard the task of up dating and reorganising the records, policies and procedures. She is introducing an audit system which should identify the work required. Carlton Villas J52 S1303 Carlton Villas V226810 170505 Stage 4.doc Version 1.30 Page 18 At the last inspection it was noted that the fire test records were not being kept up to date. This was found to be still the case at this inspection. The inspector also advised that a fire training practice is now due. Carlton Villas J52 S1303 Carlton Villas V226810 170505 Stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 1 3 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 x x x x 2 x 2 Carlton Villas J52 S1303 Carlton Villas V226810 170505 Stage 4.doc Version 1.30 Page 20 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. 5. 6. 7. 8. Standard OP1 OP2/OP9 OP3 OP7 OP7 OP8 OP36 OP38 Regulation Reg 4 Reg 5 Reg 14 Reg 15 Reg 17(2) Reg 12(1)(a) Reg 21 Reg 24(4) Requirement A copy of the statement of purpose and user guide must be provided to the CSCI. Section 8 in the Terms and Conditions regarding medication must be amended. Pre-admission assessments must be available for all service users. Up to date care plans and assessments must be available for each service user A photograph of each service user must be provided on their file. A system of health care assessment and monitoring must be put in place. A staff supervision and appraisal system must be put in place. A fire practice must be held for all staff. Timescale for action 01/07/05 01/07/05 01/07/05 01/08/05 01/07/05 01/08/05 01/12/05 01/07/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations J52 S1303 Carlton Villas V226810 170505 Stage 4.doc Version 1.30 Page 21 Carlton Villas 1. Carlton Villas J52 S1303 Carlton Villas V226810 170505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Carlton Villas J52 S1303 Carlton Villas V226810 170505 Stage 4.doc Version 1.30 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. 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!