Inspection on 16/01/07 for Pollard House

This inspection was carried out on 16th January 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

Pollard House 21/06/07

Pollard House 13/06/06

Pollard House 26/01/06

Pollard House 24/08/05

Pollard House 31/08/04

Pollard House 20/04/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Pollard House 68 Pollard Lane Undercliffe Bradford West Yorkshire BD2 4RW Lead Inspector Mary Bentley Key Unannounced Inspection 16 & 17 January 2007 09:45 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 Pollard House DS0000056120.V326471.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. Pollard House DS0000056120.V326471.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pollard House Address 68 Pollard Lane Undercliffe Bradford West Yorkshire BD2 4RW 01274 636208 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 Chander Shekher Kainth Mr Sohan Lal Kainth *** Post Vacant *** Care Home 28 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (16), of places Physical disability over 65 years of age (2) Pollard House DS0000056120.V326471.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th June 2006 Brief Description of the Service: Pollard House is an adapted Victorian building. It provides personal care for twenty-eight people, nursing care is not provided. The home offers care to people over the age of 65 and has 10 places registered for the care of people with dementia. Accommodation is provided on four floors and the communal rooms are on the lower ground and ground floors. The lounge on the lower ground floor is a designated smoking area for residents. The home has a stair lift and a passenger lift. There is one double room, the remainder are singles; some rooms have ensuite toilets. There are communal toilets on all the floors, close to the bedrooms and lounges. The home has five communal bathrooms, one of these has a bath hoist, and one has a disabled access shower. There is a small garden at the front the building. The home is situated on a bus route and is approximately one mile from Bradford city centre. There is limited car parking at the back of the building but roadside parking is available. In January 2007 the weekly fees ranged from £308.14 to £334.75. Hairdressing and chiropody are available at an additional cost. Pollard House DS0000056120.V326471.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 key inspection was in June 2006 and there were 28 requirements. Since then we have made one additional visit to the home and have had meetings with the owner to discuss his plans for improving the service. I did this unannounced inspection over two days; in total I spent 11.5 hours in the home. The purpose of this inspection was to assess what progress the home was making in dealing with the outstanding requirements and to look at how the needs of people living the home are being met. During the inspection I spoke to residents, staff and management, examined various records and looked around the home. The home completed a preinspection questionnaire and the information provided was used as part of the inspection. Before the visit we sent comment cards to some residents and relatives. Comment cards give people the opportunity to tell us what they think of the service. We share the information we receive with the home but we do not tell them who has given us the information. We received two comment cards from residents and two from relatives. Overall people were satisfied with the service; the information they provided is included in the report. At the end of the visit I discussed my findings with the acting manager. There are 21 requirements following this inspection, 10 of these are unmet requirements from previous inspections. Pollard House DS0000056120.V326471.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: Further improvements are needed across all areas of the service. The written information about the home must be more detailed and the presentation must be improved so that people have clear information about the services being offered. In order to make sure that residents’ needs are met the care plans must be improved. Residents and/or their representatives must be given the opportunity to be involved in care planning so that their wishes on how care is to be given are taken into account. In order to improve the quality of life experienced by people in the home there must be improvements to the way in which social care needs are dealt with. Pollard House DS0000056120.V326471.R01.S.doc Version 5.2 Page 7 The home must look at how staffing is organised to make sure that there are enough staff to meet residents’ needs. The systems for appointing new staff must be improved so that residents are not placed at unnecessary risk. The way in which staff training is organised and recorded must be improved so that training needs are not overlooked and staff are up to date with compulsory training. The way in which staff supervision is managed must be improved so that staff get the support they need to meet residents’ needs. The management team must work towards creating a more open and inclusive atmosphere that encourages residents and staff to share their views on how the home is being run and could be improved. 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. Pollard House DS0000056120.V326471.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 Pollard House DS0000056120.V326471.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, 2, 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. More work needs to be done on the written information available for people using the service, or thinking about using the service, to make sure that they have detailed and accurate information about the range of services offered. The information must be presented in a format that is appropriate to the needs of residents and/or their representatives. EVIDENCE: The acting manager has reviewed the Statement of Purpose and Service User Guide; they have been combined in one document. Further changes are needed to make sure that these documents include all the required information and are easy for people to use. In November 2006 we met with the owner and acting manager and gave them detailed feedback on the drafts of the Pollard House DS0000056120.V326471.R01.S.doc Version 5.2 Page 10 Statement of Purpose and Service User Guide. It was therefore disappointing to find that these documents had not been completed to the required standard. There were copies of the service guide in residents’ bedrooms. The contracts (Terms and Conditions) have been reviewed and provide clear information for residents. Two residents said they had received contracts. There have not been any admissions since September 2006. At that time we were concerned that the pre-admission assessments were not detailed enough to show that the home would be able to meet the needs of prospective residents. We discussed these concerns with the owner and acting manager. Since then the acting manager has developed a new pre-admission assessment form. It is designed to make sure that the home gets a detailed picture of the needs of prospective residents before admission. One resident said they had visited the home before deciding to move in. Pollard House DS0000056120.V326471.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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The personal and health care needs of residents’ are being met however the care records must be improved to make sure that care is delivered in a consistent way and in accordance with residents’ wishes. EVIDENCE: At the last inspection we were concerned that the care plans did not have enough detailed information to enable staff to meet people’s needs. No real progress has been made with improving the care records. Some new paperwork has been introduced but it was evident that staff had not been given clear information about what they were trying to achieve. Some staff were concerned that some of the tick box forms that were being implemented were moving them away from an individualised approach to care planning. Good quality photographs of residents are now included in the care records. Pollard House DS0000056120.V326471.R01.S.doc Version 5.2 Page 12 However, there was evidence that health care needs were being dealt with. The deputy manager was in the process of updating the assessments and had been in touch with some families and GPs to get more information about people’s medical histories. She was also trying to organise reviews of medication. Working with the district nurses she has arranged for a speech therapist to visit one resident and a dietician to visit another. Pressure relief equipment has been provided, where needed, by the district nurses. A food chart had been put in place for one resident because of concerns that she was not eating or drinking enough. Weighing scales that residents can sit on have been provided and the deputy manager said it was now much easier to get an accurate reading of residents’ weights and to keep track of weight loss or gain. Generally the systems for dealing with medicines were satisfactory, medicines are stored safely, and a new medicines fridge has been provided. There was some evidence of secondary dispensing, (removing medicines from their original containers and putting them in pots to be given at a later time). This is not safe practice and was discussed with the deputy manager. Two staff have done advanced training on the safe management of medicines, two more are booked to do this training. Residents said they usually get the care and support they need. It was evident that staff have good relationships with residents, they know them well and respect their individuality. Pollard House DS0000056120.V326471.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 adequate. This judgement has been made using available evidence including a visit to this service. There has been some improvement in this area. However, more work is needed to improve the quality of life experienced by everyone living in the home. EVIDENCE: Generally staff are more aware of the need to make social care an integral part of people’s daily lives. However, because of the diverse needs of the resident group they are finding it difficult to make sure that the social needs of all residents are addressed. Staff time is mainly spent with those residents that are most able to make their needs known often at the expense of those who may be equally dependant but less able to communicate this need. Pollard House DS0000056120.V326471.R01.S.doc Version 5.2 Page 14 There is no structured approach to the provision of activities; it is left to staff to fit them in when and where they can so there is no guarantee that they will happen and no opportunity for residents to plan or indeed look forward to an event. For example staff said one resident had really enjoyed a bingo session and kept asking when the next one would be. The deputy manager said she is planning to draw up an individual activities plan for each resident, she understands the need to provide one to one time for residents as well as group activities. Some activities were recorded in a diary but there was no information about who had taken part and whether they had enjoyed it or not. Generally the daily records give very little information about how people spend their time. One resident goes out regularly on her own, she goes to a day centre and to an exercise group every week. Another resident goes out regularly with his family, he said it if wasn’t for his family he would never have the opportunity to go out. One resident had been shopping before Christmas and had gone to the city centre to see the lights; she said she had enjoyed it very much. The daily routines are reasonably flexible and people get up and go to bed when they choose. Some residents clearly prefer to spend time in their own rooms and are supported in doing this. Generally residents were satisfied with the food. One resident said, “I have no complaints about the food”. One resident had complained about the lack of variety of puddings offered to diabetic residents and the home is dealing with this. They have purchased a book on cooking for diabetics. The menus are still being revised to give more detail on the meals being offered. There is a notice board in the dining room on which staff put details of the lunchtime meal every day. It is a set meal at lunchtime but alternatives are provided if people do not like the main course. There is a choice at teatime and I heard the afternoon cook asking residents what they wanted for their evening meal. There is also a choice at breakfast, the records showed that one resident had porridge and another resident said he had enjoyed a bacon sandwich. Supper is served at 8.00pm. Pollard House DS0000056120.V326471.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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There has been an improvement in this area but more needs to be done to make sure that everyone involved with the service is aware of how to raise concerns and knows how their concerns will be dealt with. There are policies and procedures in place to make sure that residents are protected. EVIDENCE: The home has a complaints’ procedure and this is included in the service user guide, which is in most of the bedrooms. Residents said staff listen to them and take notice of what they say and usually they know who to talk to if they have any concerns. Relatives said they were not aware of the complaints procedure. Following the last inspection we received a complaint. The person making the complaint was not satisfied with the way the home had dealt with an Adult Protection issue. The owner investigated and responded to the complaint but the person making the complaint was not satisfied with the outcome and Pollard House DS0000056120.V326471.R01.S.doc Version 5.2 Page 16 expressed a lack of confidence in the acting manager. We discussed these concerns with the owner. Complaints are recorded but the format is not suitable, suggestions were made as to how this could be improved. The deputy manager has a good understanding of the Adult Protection procedures. Other staff showed a good understanding of the need to respect residents’ rights, for example one member of staff raised concerns about how a resident’s right to independence was being compromised. We discussed how the home might deal with this and the deputy manager arranged for a review to take place. However, this issue did not just arise on the day of the visit, it had been worrying staff for several weeks and I was concerned that the acting manager had not dealt with it. There is no information in the home about advocacy services that are available to support residents and/or their representatives. Pollard House DS0000056120.V326471.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, 21, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean and comfortable. Improvements have been made and the owner is committed to continuing to upgrade the environment and facilities to make sure that people live in a safe and pleasant home that is suitably equipped to meet their needs. EVIDENCE: The home was clean and tidy. There was a slight odour in two bedrooms but staff were aware of the problems and were dealing with them. The owner continues to make improvements, a number of rooms have been decorated and have had new carpets fitted. Pollard House DS0000056120.V326471.R01.S.doc Version 5.2 Page 18 Door locks have been fitted to all the bedroom doors and two residents have keys to their rooms. The records showed that residents had either been offered keys or a risk assessment had been done to show why it would not be appropriate. In some bedrooms residents had their personal belongings around them. Residents said they liked their bedrooms. The home has five communal bathrooms however only 2 of these are assisted and suitable to be used by residents. The owner is aware that this will have to be addressed as part of the ongoing refurbishment of the home. The communal toilets need to be refurbished. Some residents smoke in their bedrooms, the management will have to address this as it has implications for the safety and wellbeing of other residents. Door guards have been fitted to some bedrooms where residents prefer to keep their bedroom doors open. The path around the outside of the home is very uneven. This increases the risk of people falling and means that residents cannot walk around outside unless they are accompanied. This is limits their opportunities for independence. The records showed hot water temperatures were last checked in November 2006. Generally they were within the recommended limits, but one or two rooms were showing low temperatures and it was not clear what, if anything, had been done about this. The person working in the laundry should wear gloves and aprons to reduce the risk of cross infection. It is not appropriate to use black sacks for dirty laundry because they could easily be mistaken for rubbish and thrown out. Pollard House DS0000056120.V326471.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 adequate. This judgement has been made using available evidence including a visit to this service. There are enough staff to make sure residents are safe but staff do not always have the time to deal with residents’ social needs. Recruitment procedures are not followed consistently and this creates the opportunity for residents to be placed at risk. EVIDENCE: There are 3 care staff on duty during the day (8.00am to 8.00pm) and 2 at night. This does not include the manager. Separate staff are employed for housekeeping and cooking. While these numbers are sufficient to keep residents safe they do not take account of the dependency of some of the residents, or the layout of the building and this means that staff have very little time to devote to social care. The acting manager said he was in the process of recruiting an activities organiser and had booked 2 places for staff on a training course on providing activities for older people. Pollard House DS0000056120.V326471.R01.S.doc Version 5.2 Page 20 The National Minimum Standards recommend that 50 of the care staff are trained to NVQ (National Vocational Qualification) level 2 or equivalent. Four staff have an NVQ at level 2 or above, this equates to 26 of the care staff team, and another five staff are doing NVQ training. Funding has been secured for the deputy manager to do an NVQ level 4 but a course date has not yet been confirmed. Eight staff attended a training day on the common induction standards on the day before the inspection. The subjects covered included confidentiality, adult protection, and health and safety and staff said they had found it helpful. Some training on dementia care has taken place and more training is booked. The systems for recording and planning training need to be improved to make sure that that information is readily available and training needs are not overlooked. One person’s recruitment file showed that all the required checks had been done before she started work in the home. She had attended induction training with an external training provider. Another staff file did not have all the required information and there was no record that a POVA (Protection of Vulnerable Adults) check or a CRB (Criminal Record Bureau) check had been done before she started work. There was no information available about another member of staff shown on the duty rota. The acting manager said she was a volunteer but there was no paperwork to show that the home had carried out the required checks or confirmed they had been done by another organisation. None of the files contained confirmations of job offers, contracts of employment or job descriptions. Pollard House DS0000056120.V326471.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, 32, 33, 34, 35, 36, 37 & 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There have been some improvements since the last inspection. However, the rate of improvement is slow and there are still a significant number of outstanding issues that compromise the well being and in some cases the safety of residents. EVIDENCE: At previous inspections we have expressed concerns that the home has not had a registered manager for approximately 2 years, the acting manager is Pollard House DS0000056120.V326471.R01.S.doc Version 5.2 Page 22 now in the process of applying for registration. He is studying for the registered managers award. The owner visits the home at least once a month and looks at all aspects of the service; we receive detailed reports of these visits. Residents’ meetings took place in September and December 2006 and a staff meeting was held in December 2006. The notes of these meetings should be made available in the home for people who, for whatever reason, did not attend the meetings. This was discussed with the acting manager at the last inspection. Some staff felt the acting manager did not communicate a clear sense of direction and leadership and this meant they were not always clear about their roles and responsibilities. Similar concerns have been raised at previous inspections and we discussed them with the owner in August 2006. The acting manager said questionnaires had been sent to relatives in October 2006 but none had been returned. In May 2006 he had met with some relatives to get their views of the service and notes of these meetings were seen. The quality assurance systems need to be developed to make sure that people using the service have the opportunity to share their views and contribute to the development/improvement of the service. The insurance certificate was due to expire on 19 January 2007; the acting manager said he would follow this up. The home holds small amounts of personal money for some residents. The records showed that all transactions are recorded and receipts are kept. Receipts are numbered to make it easier to audit the records. The owner checks the records and relatives are asked to check them from time to time; this is good practice. Some staff supervision has taken place but there is no system to show clearly when staff have received supervision and when the next one is due. The acting manager said he had done a group supervision with some staff in December 2006 but there was no record of this. Some records required by regulation were not available, for example some staff files did not have all the required information. There were other shortfalls with regard to records, an example being that the Statement of Purpose does not contain all the required information. At the last inspection we spoke to the acting manger about putting a system in place for auditing accidents, this has not been done and was discussed again during this visit. Discussions with the deputy manager confirmed that appropriate follow up action is taken following accidents. Pollard House DS0000056120.V326471.R01.S.doc Version 5.2 Page 23 The hoists were last serviced in March 2006; to comply with the regulations on lifting equipment (LOLER Regulations 1998) they must be serviced every 6 months. The records showed that the weekly fire alarm test was overdue; the acting manager said it had been done but not recorded. Other maintenance checks and service records were up to date. The records showed that none of the staff were up to date with fire training. There were some fire drills last year but not all the staff had taken part in a drill and there was no drill involving the night staff. Staff had attending training on the theory of moving and handling and were due to have their practical training updated. A new hoist has been provided but staff have not been trained on how to use it meaning that residents and staff could be at risk of injury. Pollard House DS0000056120.V326471.R01.S.doc Version 5.2 Page 24 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 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 2 2 X X 3 3 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 2 3 2 2 2 Pollard House DS0000056120.V326471.R01.S.doc Version 5.2 Page 25 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 registered persons must make sure that the Statement of Purpose and Service User Guide include all the information specified by regulation. Copies of the updated documents must be sent to the CSCI. Previous timescale of 15/09/06 not met. Every resident must have a care plan that sets out in detail how personal, health, and social care needs will be met. Timescale for action 30/03/07 2 OP7 15 30/03/07 3 OP7 12(1) & 17(1) Previous timescale of 28/04/06 & 15/09/06 not met. 30/03/07 The registered persons must make sure that the care records accurately reflect how the health care needs of residents are being met. Previous timescale of 15/09/06 not met. The registered persons must DS0000056120.V326471.R01.S.doc 4 OP9 13(2) 16/02/07 Version 5.2 Page 26 Pollard House 5 OP12 16(2) make sure that medicines are administered safely. The registered persons must provide a programme of activities that takes account of the needs, preferences and capabilities of service users. Previous timescales of 28/10/05, 24/03/06, 31/05/06 and 15/09/06 not met. The complaints procedure must be made available to residents and/or their representatives in an appropriate format. Previous timescale of 15/09/06 not met. The registered persons must keep a record of all complaints showing the details of the complaint, the action taken, and the outcome. The registered persons must make sure that the paths around the outside of the home are maintained so that they are safe for residents to use. The registered persons must make sure that there are enough suitably equipped baths/showers for residents use. The registered persons must make sure that staff adhere to safe working practices to reduce the risk of cross infection. Previous timescale of 31/10/06 not met. The registered persons must review the staffing levels to make sure there are always enough staff on duty to meet residents needs. Previous timescale of 18/08/06 & 31/10/06 not 30/03/07 6 OP16 22 30/03/07 7 OP16 22 & 17 30/03/07 8 OP20 23 30/03/07 9 OP21 23 30/04/07 10 OP26 13(3) 30/03/07 11 OP27 18 28/02/07 Pollard House DS0000056120.V326471.R01.S.doc Version 5.2 Page 27 12 OP29 19 13 14 OP30 OP32 17 Sch. 4 10 & 12 15 OP33 24 met. The registered persons must not allow new staff to start work in the home until all the required checks have been completed and all the documents specified in Schedule 2 are available. The registered persons must keep records of all training done by staff. The registered persons must make sure that the management approach to the home creates an open, positive, and inclusive atmosphere and that staff are given clear information about their roles and responsibilities. The registered persons must implement and maintain a quality assurance system based on seeking the views of service users. The findings of these reviews must be made available to service users. Previous timescale of 28/04/06 & 30/09/06 not met. The registered persons must make sure that staff receive supervision and appropriate records are maintained. The registered persons must make sure that all the records required by regulation are kept up to date and in good order and are available for inspection. Previous timescale of 18/08/06 & 31/10/06 not met. The registered persons must make sure that staff are given the training they need to enable them to work safely when helping residents to move either manually or with equipment. Previous timescale of DS0000056120.V326471.R01.S.doc 16/02/07 30/03/07 30/03/07 30/03/07 16 OP36 18 30/03/07 17 OP37 17 30/03/07 18 OP38 13(5) 28/02/07 Pollard House Version 5.2 Page 28 19 OP38 23 20 OP38 13(4) 21 OP38 13(4) 28/07/06 & 31/10/06 not met. The registered persons must make sure that all staff undertake fire training at least twice a year. The registered persons must make sure that hoists and lifts are serviced at six monthly intervals. The registered persons must carry out a detailed risk in relation to the practice of residents smoking in their bedrooms. This must include information on how the risk of fire a fire is being managed and the impact on other residents who may be exposed to the effects of passive smoking. 28/02/07 28/02/07 30/03/07 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 OP14 OP15 OP28 OP38 Good Practice Recommendations The home should provide information for residents and/or representatives about advocacy services. The menus should set out in detail the food choices that are available to residents and should be made available to residents. 50 of care staff should be qualified to NVQ level 2 or equivalent. An audit of all accidents should be done at least once a month. Pollard House DS0000056120.V326471.R01.S.doc Version 5.2 Page 29 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. 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