Inspection on 07/03/07 for Carlton Villas

This inspection was carried out on 7th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 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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Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

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 09:30 7 March 2007 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 DS0000001303.V312703.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. DS0000001303.V312703.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 Miss Tanya Louise Winter 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) DS0000001303.V312703.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st October 2005 Brief Description of the Service: Carlton Villa is a detached converted property. The home provides accommodation for 13 older people 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. It is well served by local transport. The home offers personal care, nursing care is not provided. There is good disabled access into the home and there is a small car park at the front of the building. The home has a conservatory and a pleasant garden. A specialist unit is being built in the grounds to provide supported living for people with autism. When it is completed the unit will be run independently of the care home. In August 2006 the home told us the weekly fees were £345.00. Additional services such as hairdressing, newspapers, and transport can be arranged for an extra cost. DS0000001303.V312703.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 we made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate”, and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk The last inspection was in October 2005 and there were seven requirements. We have not made any additional visits to the home since then. The purpose of this inspection was to look at how the needs of people living in the home are being met. I did this unannounced inspection in one day and spent approximately 7 hours in the home. During the visit I talked to 3 residents and 3 visitors. I also spoke to staff, and management, examined various records, looked at most parts of the home and observed care staff caring for residents. The home completed a pre-inspection questionnaire last year and some of that information was used during this inspection. The home was asked to provide additional information in January 2007 and this was provided during the visit. The manager was not available during the visit, the deputy manager, and owner helped with the inspection process. At the end of the visit I talked to the owner about my findings. Comment cards were left at the home for residents and relatives. Comment cards give people the opportunity to share their views of the service with us. The information we receive is shared with the home without identifying who has provided it. Two comment cards were returned; the information provided has been included in this report. DS0000001303.V312703.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The written information available for prospective residents needs to be improved so that people have the information they need to help them decide if the home is suitable for them. The care records need to be improved so that care can be delivered in a consistent way that takes account of residents’ wishes. One person said personal care could be improved by more attention to detail and residents being able to have a bath more than once a week. DS0000001303.V312703.R01.S.doc Version 5.2 Page 7 A number of people felt there should be more going on in the home to keep residents interested and stimulated, the owners already have plans to address this. Two people said more care should be taken with laundering residents’ personal clothing, particularly separating dark and light colours so that clothes do not get discoloured. The home must make sure that all complaints are dealt with appropriately so that people who use the service can be confident they will be listened to and their concerns will be acted on. For the protection of people living in the home and to make sure that residents rights are upheld staff must receive training on adult protection. There are four requirements from this inspection; three of these are carried forward from previous inspections. 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. DS0000001303.V312703.R01.S.doc Version 5.2 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 DS0000001303.V312703.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, & 5. Standard 6 does not apply to this service. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are encouraged to visit the home before making a decision about admission. The written information provided needs to be improved so that prospective residents have clear information about the range of services offered. EVIDENCE: Some work has been done on the Statement of Purpose but it has not been completed. This is outstanding from the last inspection. Pre-admission assessments were seen in the care records looked at, two of these had been completed on the day of admission. The owner said they were DS0000001303.V312703.R01.S.doc Version 5.2 Page 10 emergency admissions and the manager had gone to see the residents before they came to the home. Two relatives said they had been given enough information to help decide if the home was suitable and one said they had looked around before admission. Another relative said they had not been given any information before admission. DS0000001303.V312703.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home needs to make sure that the written care plans accurately reflect the care and support they are offering to residents. This will make sure that care is delivered in a consistent way. EVIDENCE: I looked at the care records of three residents, two of these in detail. The home is in the process of updating the care plans. Some core care plans have been introduced to provide basic instructions for staff and the home is aware that they need to be personalised to take account of residents’ individual preferences. Training is being organised for staff on how to complete the new care plans. DS0000001303.V312703.R01.S.doc Version 5.2 Page 12 It was clear from talking to staff that they know the residents well and understand their individual needs and preferences. However, this information must be recorded so that care needs are not overlooked. Risk assessments were in place for falls, nutrition, and the risk of developing pressure sores. In some cases the weight records had not been completed for several months. Staff said there had been a problem with the scales but they have now been replaced. Some residents may find it difficult to balance on the scales and this will make it difficult to record weights accurately. Consideration should be given to providing scales that people can sit on. Residents confirmed that they have access to a range of NHS services including chiropody and eye tests. If residents need specialist care this is arranged through their GPs, for example one resident has been referred to a skin specialist. The district nurses provide nursing care if it is needed. The deputy manager said the home gets very good support from the district nurses. Residents said they felt well cared. One relative said that although she visits every day staff always phone her if there is any change in her mother’s condition. Another person said they thought personal care could be improved. They felt residents should be able to have more than one bath a week. They also said more attention should be given to making sure that people are wearing clean clothes and are helped to keep their nails clean. Overall the systems for dealing with medicines are safe. A risk assessment should be done for any residents who are taking their own medicines. Residents are treated with respect and kindness. DS0000001303.V312703.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Daily routines are flexible and take account of residents’ wishes. More attention needs to be given to meeting residents’ social care needs. EVIDENCE: Daily routines are flexible, people get up and go to bed when they want and can stay in their own rooms or use the communal areas. There is a conservatory where people can see visitors in private if they do not to use their bedrooms. Visitors are welcome at any time. The care plans contained detailed personal profiles of residents but there was little or no information about how social care needs would be addressed. Staff spend time chatting with residents when they can. Organised activities include bingo, dominoes, and board games. There are books, videos, and DVDs available for people. The home also organises trips to the theatre, in DS0000001303.V312703.R01.S.doc Version 5.2 Page 14 December 06 and January 07 there were 2 trips to the Alhambra to see the pantomime. There was music playing in the lounge during the morning, the TV was not turned on until late afternoon. During the morning staff were seen sitting and chatting to residents and the residents clearly enjoyed this. When staff are busy, as they were on the afternoon of the visit attending a training session, some residents find it difficult to occupy their time meaningfully. Some people said they get bored sitting around. Some relatives also said they thought there was not enough going on to keep residents stimulated. The owner said an activities organiser has been employed for another home and would also be working at Carlton Villa. Some residents go out with relatives and some said they like to sit outside when the weather is fine. Some residents go out regularly, with staff, for short walks. Overall residents were satisfied with the food. There is a set meal at lunchtime but an alternative is offered if people do not want this. Choices are offered at breakfast and teatime. Residents confirmed supper is provided. The lunchtime meal on the day of the visit was nicely presented and residents said they enjoyed it. They said the food is usually good. Staff said they thought residents had a varied and balanced diet, they said it was difficult to introduce new things to the menu, as people preferred more traditional meals. A relative said it would be helpful if the menu were displayed each day to help people with short-term memory problems. DS0000001303.V312703.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. In order to make sure that residents and their representatives have confidence in the complaints’ procedure all complaints and concerns must be dealt with in accordance with the home’s procedures. To make sure that residents are protected all staff must receive adult protection training. EVIDENCE: The required policies and procedures are in place. The home has a system for recording complaints; none had been recorded since the last inspection. One person said they had written to the owners in the past and had not received a reply but it was not clear when this was. We were contacted about one complaint since the last inspection; this was later withdrawn and dealt with by the home. The majority of people are aware of how to make a complaint. Residents and relatives said they talk to the manager or the owners if they have any concerns. DS0000001303.V312703.R01.S.doc Version 5.2 Page 16 The local authority Adult Protection procedures are available in the home. The manager has attended Adult Protection training. Staff have not had training on Adult Protection, this is outstanding from the last inspection. They have some awareness of the issues relating to abuse and protection because of other training they have attended. However, this training must be arranged so that staff can be confident that they know what action to take if they have concerns. DS0000001303.V312703.R01.S.doc Version 5.2 Page 17 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, 20, 24 & 26 Quality is this outcome area is good. This judgement has been made using available evidence including a visit to this service. Carlton Villa is homely and comfortable; it provides a clean and safe place for people to live. More care should be taken with the laundering of residents’ personal clothing. EVIDENCE: The home was clean and there were no unpleasant odours. Residents said it is always clean. The programme of refurbishment continues and the rooms identified at the last inspection have been redecorated. An Environmental Health Officer inspected the home in November 2006 and the matters raised have been dealt with. DS0000001303.V312703.R01.S.doc Version 5.2 Page 18 Residents’ bedrooms are comfortable and there was evidence that residents are encouraged to have their personal belongings with them. The communal rooms are on the ground floor; there is a dining room, a lounge, and a conservatory. They are pleasant rooms and are suitably furnished. There is not a lot of storage space and this means that the medicines trolleys are kept in the dining room, however they do not get in the way of residents using the room. The laundry facilities are sufficient to meet residents’ needs. The location of the machines is not ideal; the owner said she has plans to address this. Two people expressed concerns about the standard of laundry. One concern was that dark and light colours are not always separated and this results in whites turning grey. Another was that the wrong clothes are sometimes put in residents’ rooms. Hand washing facilities and alcohol based hand gels are provided to help reduce the risk of cross infection. Staff have received training on infection control. DS0000001303.V312703.R01.S.doc Version 5.2 Page 19 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing levels reflect the fact that the home provides care for people with low to medium care needs. If there is a significant increase in the amount of help that people need to carry out their daily activities staffing levels will need to be reviewed. Residents are protected by the home’s recruitment procedures. EVIDENCE: The home has a set two weekly rota. The full names of staff should be shown on the rota. There are usually 3 staff on the morning shift and 2 on the evening shift. The night shift is from 10.00pm to 8.00am, there is one carer in the home, and a nurse who lives next door is on call if she is needed. On weekday mornings there is a cleaner and a cook on duty, at weekends care staff are responsible for cleaning and cooking. The manager is allocated some supernumerary time every week, in her absence this time is allocated to the deputy manager. DS0000001303.V312703.R01.S.doc Version 5.2 Page 20 Residents said staff were “good”, “kind” and looked after them well. Three of the ten staff have an NVQ (National Vocational Qualification), this equates to 30 of the staff team excluding the manager. The National Minimum Standards recommend that 50 of staff are qualified to NVQ level 2 or equivalent. On the day of the visit the remaining staff signed up for NVQ level 2 training. I looked at the files of two staff that were employed since the last inspection. The records showed that all the required checks are done before new staff start work in the home. The home has devised an induction checklist for new staff. The Skills for Care induction standards should be used to make sure that new staff are supported in getting the knowledge and skills they need to meet residents’ needs. Staff said they have done a lot of training, including moving & handling, fire safety, health & safety and infection control and evidence of this was seen in the training records. On the day of the visit there was a training session on the safe management of medicines and this was well attended. Staff said they had not had any training on caring for people with dementia. DS0000001303.V312703.R01.S.doc Version 5.2 Page 21 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, 36, 37 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the home is well managed, residents are given the opportunity to share their views of the service, and there are good systems in place for dealing with health and safety. The owners are spending more time in the home to make sure it runs smoothly during the manager’s absence. EVIDENCE: When I visited the home the manager was absent due to illness. She enrolled on a course to do the registered managers award in September 2006 and has not yet completed this training. DS0000001303.V312703.R01.S.doc Version 5.2 Page 22 In the manager’s absence the deputy manager is taking charge of the day-today running of the home and is being supported by the owners. The owner said quality monitoring questionnaires are sent to relatives once a year. They were sent approximately three weeks ago but none had been returned at the time of the visit. The home deals with the personal money of one resident, there is a record of all transactions, and receipts are kept. The deputy manager deals with this and always gets two signatures for cash transactions; this is good practice. There is a system in place for staff supervision and appraisals; the owner is dealing with this while the manager is unavailable. The records showed that equipment is maintained and serviced at the required intervals, for example the hoists and stair lift are serviced every 6 months. The system for analysing accidents every month has lapsed, accidents have not been analysed since September 2006. To comply with Data Protection law the accident forms should be stored in individual residents’ files when they have been audited. The visitors’ book had been mislaid; this was discussed during the visit and will be replaced. DS0000001303.V312703.R01.S.doc Version 5.2 Page 23 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 X 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X X X 3 X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 2 3 DS0000001303.V312703.R01.S.doc Version 5.2 Page 24 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 4&5 Requirement The Statement of Purpose must be completed and made available in the home so that prospective and existing residents have clear information on the range of services being offered. A copy must be sent to the CSCI. Previous timescale of 31/12/05 not met. Every resident must have a care plan setting out in detail how their personal, health, and social care needs will be met so that care can be delivered in a consistent way that takes account of residents’ wishes. The registered persons must make sure that all complaints are dealt with in accordance with the home’s complaints’ procedure and that the required records are kept so that people using the service can be confident their concerns will be taken seriously and acted on. DS0000001303.V312703.R01.S.doc Timescale for action 06/07/07 2. OP7 15 06/07/07 3 OP16 22 & 17 06/07/07 Version 5.2 Page 25 4 OP18 13(6) All care staff must receive training on Adult Protection, to include the multi-agency approach to dealing with allegations and suspicions of abuse so that residents are protected. Previous timescale of 01/03/06 not met. The CSCI must be provided with details of this training, including details of the training provider, the dates of the training and the names of staff attending. 06/07/07 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 2 3 4 Refer to Standard OP8 OP26 OP27 OP30 Good Practice Recommendations Consideration should be given to providing scales that residents can sit on. More care should be taken with the laundering of residents’ personal clothing. The full names of staff should be shown on the duty rota. Staff should receive training on the care of people with dementia. The home should introduce the Skills for Care induction standards for new staff. 5 OP38 Accidents should be analysed every month and where necessary action taken to reduce the risk of recurrence. Accident forms should be stored in individual residents’ files when the monthly audit has been completed. DS0000001303.V312703.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 DS0000001303.V312703.R01.S.doc Version 5.2 Page 27 - 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. 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