Inspection on 31/10/07 for Carlton Villas

This inspection was carried out on 31st October 2007.

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 07/03/07

Carlton Villas 21/10/05

Carlton Villas 17/05/05

Carlton Villas 07/12/04

Carlton Villas 05/08/04

Carlton Villas 17/02/04

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Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

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Carentan House

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 West Yorkshire BD2 3DB Lead Inspector Mary Bentley Key Unannounced Inspection 31st October 2007 09:30 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.V354026.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Carlton Villas DS0000001303.V354026.R01.S.doc Version 5.2 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 *** Vacant *** 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.V354026.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7 March 2007 Brief Description of the Service: Carlton Villas is a detached converted property. The home can care for up to 13 people. The home offers personal care, nursing care is not provided. The accommodation consists of nine single and two double bedrooms, two of which have en-suite facilities. The communal rooms are on the ground floor; there is a lounge, a conservatory, and a dining room. There is good disabled access into the home. Inside there is a stair lift to the first floor, the home does not have a passenger lift. There are 3 communal bathrooms, one of which has an assisted bath. The home has a small but pleasant garden that people can use, weather permitting. There are a small number of car parking spaces in the grounds and parking is allowed on the roadside. The home is close to a good range of local amenities including shops, public houses, a library, and a park. It is well served by local transport. A specialist home for people with a learning disability is being built in the grounds. When it is completed the unit will be run independently of the care home. In October 2007 the home told us the weekly fees were £365.00. Additional services such as hairdressing, private chiropody, newspapers, and transport can be arranged for an extra cost. Copies of inspection reports are available from the home on request. Carlton Villas DS0000001303.V354026.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We did this unannounced inspection in one day and spent approximately 6 hours in the home. During the visit we spoke to staff, people living in the home, and management. We looked at various records, including three people’s care plans and looked at some parts of the building. Before the inspection we sent surveys (comment cards) to people living in the home, their relatives and some health and social care professionals such as GPs and social workers. Surveys give people the opportunity to tell us what they think about the service. The information we get is shared with the home but we do not identify who has provided it. We received 4 surveys from relatives of people living in the home. The home completed a self-assessment form for us before the visit. It was sent back to us in good time. This report includes information from the self-assessment, the surveys, our records relating to the service and our site visit. What the service does well: What has improved since the last inspection? Carlton Villas DS0000001303.V354026.R01.S.doc Version 5.2 Page 6 The home has made changes to the laundry systems and they told us people have said this has improved the way people’s personal clothing is cared for. The home has started having meetings for people living in the home, and their relatives, so that people have the opportunity to say what they think about the service and to make suggestions for improvements. The acting manager has produced a newsletter giving people information about what is happening in the home and plans to continue with this. Work is being done to improve the environment to make sure the home continues to provide a pleasant place for people to live. There is an ongoing programme of staff training to make sure that staff have the skills and knowledge they need to care for people properly. 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. Carlton Villas DS0000001303.V354026.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Carlton Villas DS0000001303.V354026.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3. Standard 6 does not apply to this service. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. There is information available to help people decide if the home is suitable for them or their relatives. People’s needs are assessed before they move in. EVIDENCE: There is a Statement of Purpose and a Welcome Pack, which give people information about the range of services offered. The relative of someone who moved to the home recently told us that had not been given a contract (Terms and Conditions). The acting manager confirmed this and said it was being dealt with at head office. The home told us everyone else has now been given a contract. Carlton Villas DS0000001303.V354026.R01.S.doc Version 5.2 Page 9 The acting manager explained in detail how people’s needs are assessed before they are offered a place. This includes visiting them wherever they are living and inviting them, or people close to them, to visit the home before they move in. Carlton Villas DS0000001303.V354026.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Generally people’s needs are met. However, because people or those close to them are not involved in drawing up the care plans there is a risk that care may not always be delivered in a way that takes accounts of people’s individual needs, preferences and abilities. EVIDENCE: Everyone has a care plan and we looked at three people’s care plans. The care plans have information about how people’s personal and health care needs will be met. More work is needed to make sure that the plans give a clear picture of what people can do for themselves and what they need help with. For example, instead of saying “assist with” the plan should make it clear what the person can do themselves and what they need staff to help with. Risk assessments are in place dealing with areas such as falls, nutrition, continence, and the risk of developing pressure sores. Some of these Carlton Villas DS0000001303.V354026.R01.S.doc Version 5.2 Page 11 assessments are not dated and it is not clear how often they are going to be reviewed. The home works closely with the district nurses to make sure people’s health care needs are met. For example the home does their own continence assessment and refer to the district nurses if people need continence aids. Most of the care plans are reviewed every month by staff. There is no evidence that people living in the home, or those close to them, are involved in planning and reviewing care. The home does not have a sit on scales and therefore it is not possible to record everyone’s weight, this was discussed at the last inspection. The home has changed the pharmacy it uses to get people’s medicines. The acting manager said the service is better and people’s medicines are delivered quickly. Only staff that have received training are allowed to help people with their medicines. The home is dealing with a complaint that was made about the way one person was given their medicine. People looked well cared for. Staff are kind and respectful and throughout the day they chatted to people and had a laugh with them. Carlton Villas DS0000001303.V354026.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People have the opportunity to take part in some social activities in the home. However, the approach to social care is not centred on the individual needs, preferences, and abilities of people living in the home and this means that people’s social, cultural, and spiritual needs may not always be met. EVIDENCE: Daily routines are reasonably flexible and people get up and go to bed when they want. The home does not have an activities organiser but is trying to improve the way people’s social care needs are met. There are some organised activities such as bingo, films, and games. On the day we visited some people watched a film in the morning and about 5 people played bingo in the afternoon. They said they enjoyed bingo, especially winning the prizes. There are records of activities but these do not show who has taken part and whether or not they enjoyed the activity. There is very little information in the Carlton Villas DS0000001303.V354026.R01.S.doc Version 5.2 Page 13 care records about people’s past lives and interests. There are no social care plans showing how people will be helped to follow their personal interests. There is very little information about people’s religious needs; the acting manager said one or two people go out to church with friends. Some people go out with family and/or friends and sometimes people go for a walk with a member of staff. People who do not have family/friends to take them out do not get many opportunities to take part in any social events outside of the home. One person said, “They don’t have much to choose from, they get up in the morning, eat, drink and go to bed”. The lunchtime meal on the day we visited looked appetising and people said they enjoyed it. The food records showed that although there is a two weekly menu the home is actually following the same menu every week. This means that there is very little variety for people. This was discussed with the cook and the acting manager during the visit. The menus are displayed in the dining room. The home did a newsletter in July and this contains some information about the menus. It is not clear how well circulated the newsletter was because some relatives do not know that the menus are displayed. Carlton Villas DS0000001303.V354026.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are given information about how to make a complaint and complaints are taken seriously and looked into. However, more needs to be done to reassure people that they are listened to and that their concerns are acted on. People are safeguarded from abuse and neglect. EVIDENCE: Since March 2007 we have received 3 complaints about the home. We sent these to the owner to investigate using their complaints’ procedure. Two of them have been dealt with and the third one is still being investigated. Two referrals have been made to the Adult Protection unit about this service. The initial investigation of both cases showed that abuse had not taken place and the concerns raised were dealt with through our inspection process. Three of the four relatives who returned our surveys said they know how to make a complaint. However, some people did not think the home always responded appropriately. Two people said they had raised a lot of issues at the first relatives’ meeting (on 1 August) and they were still waiting to see what the outcome would be. Carlton Villas DS0000001303.V354026.R01.S.doc Version 5.2 Page 15 The acting manager has attended external training on adult protection (safeguarding). She has shared this training with other staff working in the home. Further training is planned. The staff have a reasonably good understanding of how vulnerable people should be protected and how to report any concerns. Carlton Villas DS0000001303.V354026.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 25 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Carlton Villas provides a clean, comfortable, and homely place for people to live. Improvements are being made and this needs to continue to make sure the home is suitably equipped to meet people’s needs. EVIDENCE: The home was clean. Work is being done to improve the facilities and the environment for the people living there. A new stair lift and a new bath hoist have been installed and some bedrooms have been refurbished since our last visit. Carlton Villas DS0000001303.V354026.R01.S.doc Version 5.2 Page 17 There is not much storage space in the home. This means that the medicine trolley and some paperwork are kept in the dining room and this tends to make this otherwise pleasant room seem cluttered. This was discussed during the visit. One person told us they thought the maintenance was not as good as it should be and that it seemed to take ages for things to be repaired. When we looked around the home we noticed that some light bulbs needed to be replaced and the fan in one of the bathrooms was not working. The acting manager said there have been some problems with maintenance but this is being dealt with. The home has 3 communal bathrooms but only one of these is used regularly because it has an assisted bath. The other 2 baths are not assisted and therefore people are not able to use them, this means that people’s choices are limited. There was no bath thermometer available meaning that the hot water temperature cannot be checked before people get into the bath. This creates a risk of people being scalded. The hot water temperatures have not been checked for several months. They should be checked regularly to make sure that the valves are working and hot water is being maintained at the recommended safe temperature. Since our last visit the home has made changes to the way people’s laundry is dealt with. They said people have told them these changes have improved the laundry service. The location of the laundry is not ideal, it is in a corridor, which makes it difficult to sort clothing both before and after it has been washed. The owners told us earlier this year they were looking at ways this could be improved. Carlton Villas DS0000001303.V354026.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. There are enough suitably trained staff to make sure that people get the support and care they need. People are protected because all the necessary checks are done before new staff start work in the home. EVIDENCE: There are usually 3 care staff on duty in the morning and 2 in the afternoon and evening. Overnight, from 10.00pm to 8.00am, there is one carer in the home and someone next door on call if they are needed. The acting manager said there had been some staffing problems in September, mainly due to holidays, but these are now sorted and the home is fully staffed. On weekday mornings there is a cook and a domestic assistant, at weekends care staff cover these duties. One person told us they thought the home would be better if the cook and domestic assistant also worked at weekends, this would give care staff more time to spend with people. People told us they thought it would be better if staff had names badges and wore their uniforms all the time. They said it is not always easy to remember Carlton Villas DS0000001303.V354026.R01.S.doc Version 5.2 Page 19 the names of staff. They also told us they didn’t know much about the skills and qualifications of staff. They said they had asked for a photo board with the names and qualifications of staff but this had not been done. The home does a lot of staff training, 83 of care staff have an NVQ (National Vocational Qualification) at level 2 or above. Training has also taken place on other subjects such as dementia care, the protection of vulnerable adults, and the safe management of medicines. All staff are up to date with moving and handling and fire safety training. The former deputy manager has taken on the role of cook and has started training on food hygiene and nutrition. There is an individual training record for every member of staff. The home is in the process of introducing a formal induction training package for all new staff to help them get the skills and knowledge they need to care for people properly. This is the nationally recognised Skills for Care induction. The files of two newly appointed staff showed that all the required checks are carried out before new staff start work in the home. Carlton Villas DS0000001303.V354026.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People can be assured that the owners are providing appropriate support to make sure the home is managed properly in the absence of a registered manager. EVIDENCE: Since our last visit the registered manager has left. An acting manager was appointed for a probationary period. She has been in day-to-day charge of the home for the past 5 months and has now decided to step down. A new acting manager was starting work on the Monday following our visit. Carlton Villas DS0000001303.V354026.R01.S.doc Version 5.2 Page 21 These changes have been unsettling for everyone involved with the home. It is hoped that with the new manager in post the home will be able to settle down and concentrate on continuing to improve the quality of life experienced by the people who live there. The Operations Manager provides senior management support; he oversees the management of a number of homes in the organisation and visits the home regularly. As well as providing support for the acting manager he looks at various aspects of how the home is being run and talks to people to find out what they think of the service. The organisation sends surveys to people involved with the home. They go directly to the organisation’s head office where they are looked at before being discussed with the home manager. The Operations manager said the two issues identified in the most recent surveys were about food and laundry and they are being addressed. The home holds some small amounts of personal money for people. All transactions are recorded and receipts are kept for any money spent on people’s behalf. The records showed that the fire alarm system is not checked every week, as it should be. Carlton Villas DS0000001303.V354026.R01.S.doc Version 5.2 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 3 2 3 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 X X X 2 3 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 2 X 3 X 3 X X 2 Carlton Villas DS0000001303.V354026.R01.S.doc Version 5.2 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 OP7 Regulation 15 Requirement The care plans must set out in detail how people’s personal, health, and social care needs will be met and must show evidence that people are involved in drawing up their care plans. This is to make sure that people’s needs are not overlooked and care is delivered in a way that takes account of their wishes. Previous timescale of 06/07/07 not met. People must be given the opportunity to take part in social activities that reflect their needs, preferences, and abilities so that they are supported in following their personal interests and maintaining their abilities. The bathroom on the first floor must be upgraded to an assisted bath or disabled access shower so that people have a useable bathroom close to their bedrooms and so that people have a choice of bathing facilities. DS0000001303.V354026.R01.S.doc Timescale for action 31/03/08 2 OP12 16 31/03/08 3 OP21 23 30/05/08 Carlton Villas Version 5.2 Page 24 4 OP38 23(4) To make sure the fire alarms systems are working properly they must be tested every week and a record kept. 14/12/07 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 OP2 Good Practice Recommendations When people cannot be given a contract at the time of admission, for whatever reason, they should be given an explanation, preferably in writing, of the reason for the delay. Sit on scales should be provided so that it is possible to record and monitor the weight of everyone living in the home. To reduce the risk of scalding bath thermometers should be provided so that the water temperature can be checked before people get into the bath. 2 3 OP8 OP25 Carlton Villas DS0000001303.V354026.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection 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 Carlton Villas DS0000001303.V354026.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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