CARE HOMES FOR OLDER PEOPLE
Carlton Villas 2 Pelham Road Undercliffe Bradford West Yorkshire BD2 3DB Lead Inspector
Michael Smithson Announced Inspection 09:30 21 October 2005
st 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 Carlton Villas DS0000001303.V249456.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 DS0000001303.V249456.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Carlton Villas Address 2 Pelham Road Undercliffe Bradford West Yorkshire BD2 3DB 01274 634913 0113 2509633 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) Mr John Thomas Lamb Mrs Helen Margaret Lamb Care Home 13 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (9), of places Physical disability over 65 years of age (2) Carlton Villas DS0000001303.V249456.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 17th May 2005 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 DS0000001303.V249456.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an announced inspection the second of 2 inspections for this year. The first inspection undertaken on the 17th May 2005 was unannounced. Copies of inspection reports for this and the last inspection are available either from the home or the CSCI website. A poster was on display informing the service users and relatives of the inspection and feedback comment cards were provided. The inspection took place over the morning and early afternoon and focused on the outstanding requirements and recommendations from the last inspection, records, environment and discussions with staff and service users. The feedback provided on the day of the inspection and included in the returned comment cards were very positive. All felt the home had improved since the new proposed manager took over. The home was cleaner and brighter and better organised. The staff felt they had more structure to their daily duties and had greater enthusiasm. The service users felt standards had improved and that the staff were happier in their work. What the service does well:
Carlton Villa is a small friendly home which caters for service users mainly from the local area. The home is comfortable and has a good family atmosphere. The staff team is enthusiastic and has remained stable, which helps to provide continuity of care. The manager is clear as to the levels of care they can provide and has developed good links with other agencies that can provide specialist support. The new manager felt she has received very good levels of support since taking over the role of manager. The service users felt the meals were of a good standard and were offered a choice. Carlton Villas DS0000001303.V249456.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better:
The care plans are much better than was noted at the last inspection. However further improvements were recommended. The identified needs of service users could be better recorded and be less repetitive. It is not necessary to write out a new care plan each time they are updated. The updated evaluation record can be developed to include the specific issues identified in the care plans. The risk assessments for service users contained information, which detracted from the actual risks identified. Much of the information included should be transferred to the care plans. A copy of the records for payment of personal allowances to service users must be kept at the home. The final version of the statement of purpose and service user guide must be completed and a copy provided for CSCI The staff supervision programme must now be implemented. The format produced was suitable for recording the sessions. The refurbishment of the premises must continue. Bedrooms 4, 7 and 10 should be prioritised. The provider should also consider the future use of the large bathroom on the first floor. The proposed manger must complete and return the registered manager Fit Person application so the registration process can begin. Carlton Villas DS0000001303.V249456.R01.S.doc Version 5.0 Page 7 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 DS0000001303.V249456.R01.S.doc Version 5.0 Page 8 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 Carlton Villas DS0000001303.V249456.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 1, 2 and 3. The new manager is in the process of updating the statement of purpose and service user guide. Her aim is to provide more user-friendly information. The home is clear as to the levels of care they are registered to provide. EVIDENCE: The new statement of purpose and service user guide are still being completed. The proposed manager is looking to simplify the statement of purpose and make the service user more user friendly. She is hoping to include the service user guide in a welcome pack for new admissions. This will be good practice. The new terms and conditions of residency have been changed to remove the statement regarding medication must be held and administered by the home. Service users will now be permitted to self medicate if they are capable following a risk assessment. Carlton Villas DS0000001303.V249456.R01.S.doc Version 5.0 Page 10 One service user is private fee paying and has been issued with a copy of the new terms and conditions. The remaining service users are funded by the local authority and have local authority contracts. The records for the last admission to the home included a pre-admission assessment. The information was completed during a domiciliary visit undertaken by the manager and the provider. Carlton Villas DS0000001303.V249456.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 7, 8 and 10. The care documentation for service users has greatly improved. The health and personal care needs of service users are well recorded and are well met by the staff at the home. EVIDENCE: The manager has worked very hard to improve the care documentation used at the home. The care records are much easier to follow and are better organised. The information held is now not as repetitive as was noted at the last inspection. The records also include contribution from service users and relatives. This is good practice. I checked the care records for 3 service users. The information included risk assessments, care plans and health care monitoring. The risk assessments were very detailed and included information, which would be better, included in the care plans. The risk assessments should just include the risk identified and the action required to maintain safety. The care plans were much improved, however the information held needs to be simplified. Rather than completing a new care each time they are evaluated
Carlton Villas DS0000001303.V249456.R01.S.doc Version 5.0 Page 12 each month, if there are no changes then the original care plan can be used. The current evaluation record can be adapted to include all the information in the care plans. The health care monitoring includes, nutritional assessments, pressure area care, falls assessment and manual handling. The manager was reminded that if the nutritional assessments identify risk then the service user must be weighed regularly. This must be included in the care plan so staff know to undertake this task. Carlton Villas DS0000001303.V249456.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 12, 13, 14 and 15. Carlton Villa provides a good range of activities geared to both individuals and small groups. Service users who are able, can exercise choice and maintain independence. EVIDENCE: A range of activities are offered these include, board games, videos and books. Plans are in hand to organise Xmas shopping trips. The staff felt they had time to spend with service users in and amongst the daily routines. A number of service users like to organise their own activities and tend to spend time in their bedrooms. The manager has kept relatives informed of any changes at the home and includes them in the production of the care plans and the updates. A new cook has been employed at the home and is looking at the menus. The home is small so the menus are quite flexible. A choice is offered as an alternative to the menu. The feedback from service users regarding the food was very positive. They felt the cook provided very good meals and offered different types of food. She was willing to try new things on the menu.
Carlton Villas DS0000001303.V249456.R01.S.doc Version 5.0 Page 14 Carlton Villas DS0000001303.V249456.R01.S.doc Version 5.0 Page 15 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 the following standard(s): 16 & 18 A robust adult protection and complaints policy and procedure ensures that service users are listened to and are protected from abuse. EVIDENCE: The new complaints procedure is on display in the entrance area and will be included in the statement of purpose and service user guide. No complaints had been recorded since the last inspection. Adult protection training is being organised for the staff team. Carlton Villas DS0000001303.V249456.R01.S.doc Version 5.0 Page 16 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 the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. The agreed refurbishment of the premises in still underway. A number of rooms have been improved since the last inspection. The premises are suitable for there purpose. EVIDENCE: The refurbishment plan for the premises is still being undertaken. The lounge, dinning room and conservatory have been completed since the last inspection. New carpets, curtains and bedding have been provided in a number of areas. The new decoration has made the home look brighter and is easier to keep clean. Three of the bedrooms in particular are in need of refurbishment and should be next to be refurbished. Bedroom 4 should be prioritised followed by bedrooms 10 and 7. A stair lift is available together with a fixed and mobile hoist. All are serviced on a regular basis.
Carlton Villas DS0000001303.V249456.R01.S.doc Version 5.0 Page 17 The bathrooms and toilets were maintained to a good standard of hygiene and hand washing facilities are available around the building. There is a problem with lack of storage space at the home. One option may be to use the large bathroom on the first floor, which tends not to be used. Carlton Villas DS0000001303.V249456.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30. The staff recruitment is thorough and protects the service users. The staffing has remained stable, which provides good continuity of care. EVIDENCE: The staffing has remained fairly stable with very few changes since the last inspection. There were no staff vacancies at the time of the inspection. The staff recruitment records were checked for the last 2 members of staff employed. Both contained all the information required including, application forms, references and CRB check. The proposed manager has undertaken a training audit to determine any training required. The staff have completed the majority of the mandatory training. The home is making good progress with regard to NVQ level 2 qualifications. Three of the twelve care staff have completed the training and three are undertaking the award. During the inspection interviews were undertaken with 2 of the staff. Both felt that the new proposed manager had made improvements to the home and had given the staff team more focus and structure to their daily work. Both were experienced senior care staff that showed a very good understanding of the needs of service users and the daily routines. They felt they had been given the training to enable them to perform the daily tasks to a good standard and
Carlton Villas DS0000001303.V249456.R01.S.doc Version 5.0 Page 19 were confident to be able to take charge of the home in the absence of the manager. Carlton Villas DS0000001303.V249456.R01.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38. The home is now very well run and staff are involved in the decision making process. The manger receives good support from the provider. The policies and procedures have been updated and improved. EVIDENCE: The proposed manager has worked at the home for a number of years at various levels. Her last post was the deputy manager. Since taking on the role of manager she has made significant improvements to the running of the home. The staff commitment and enthusiasm has improved and the homes records and policies and procedures are much better organised. She is in the process of completing the Fit Person registration information and is looking to enrol on NVQ level 4 and Registered Managers Award.
Carlton Villas DS0000001303.V249456.R01.S.doc Version 5.0 Page 21 A staff supervision programme is being reintroduced. A format for care assistants and senior care is being produced. A number of staff meetings have been held to keep staff up to date with any changes. The provider takes responsibility for the personal allowance for 2 of the service users. The money is paid direct to them each week. However the record of payment is not held on the premises. This must be addressed. The health and safety information is now well organised and the safety checks have been completed. The provider has now produced a suitable format for recording the Regulation 26 visits. A copy of the last visit was provided at the inspection. The new manager did feel that she received very good support from the providers. They had made arrangements for her to spend time ‘off rota’ to reorganise the records, policies and procedures. Carlton Villas DS0000001303.V249456.R01.S.doc Version 5.0 Page 22 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 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 2 3 3 3 3 3 2 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 2 2 3 3 Carlton Villas DS0000001303.V249456.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation Reg 4 Reg 5 Reg 15 Requirement A copy of the final version of the statement of purpose and service user guide must be provided for CSCI. The service user care plans need to be less repetitive and the evaluation relate specifically to issues identified in the care plans. All care staff must attend Adult Protection training. Bedrooms 4, 7 and 10 must be prioritised for refurbishment. The proposed manager must complete and return the Fit Person registration application form. The records for personal allowances given to service users must be kept on the premises. A staff supervision system must be put in place. Timescale for action 31/12/05 2 OP7 31/12/05 3 4 5 OP18 OP24 OP31 Reg 13(6) Reg 23 Reg 8(1) 01/03/05 01/03/05 21/10/05 6 7 OP35 OP36 Reg 17(2) Reg 21 21/10/05 01/12/05 Carlton Villas DS0000001303.V249456.R01.S.doc Version 5.0 Page 24 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 OP7 Good Practice Recommendations The service user risk assessment should be simplified and information regarding care issues transferred to the individual care plans. Carlton Villas DS0000001303.V249456.R01.S.doc Version 5.0 Page 25 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
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