Inspection on 21/06/07 for Pollard House

This inspection was carried out on 21st June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 16/01/07

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 Unannounced Inspection 21 June 2007 09:20 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.V335359.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.V335359.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 Vacant post 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.V335359.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2007 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 people living in the home. 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 May 2007 the weekly fees ranged from £329.00 to £364.70. Hairdressing and chiropody are available at an additional cost. Pollard House DS0000056120.V335359.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. I did this unannounced inspection in one day and spent approximately 7.5 hours in the home. Following the last inspection in January 2007 the providers gave us an improvement plan setting out how they would improve the service for the people living there. The purpose of this visit was to assess how this plan is progressing and how the service is meeting people’s needs. During the visit I spoke to people living in the home, staff and management. I looked at various records relating to care, staff, and maintenance and looked at some parts of the building. Before the visit we sent comment cards to 17 people, (7 to people living in the home, 7 to relatives and 3 to GPs). Comment cards give people the opportunity to share their views of the service with us. The information we get is shared with the home without identifying who has provided it. In total 7 cards were returned and the information we received is included in this report. Generally people were satisfied with the service. The providers completed a pre-inspection questionnaire and information from the questionnaire is included in this report. What the service does well: What has improved since the last inspection? There have been a lot of improvements since the last inspection; most of the 21 requirements made at that time have been fully or partially dealt with. Pollard House DS0000056120.V335359.R01.S.doc Version 5.2 Page 6 One of our main concerns at previous inspections was that the home did not have a registered manager. The purpose of registration is to make sure that a suitably qualified and competent person runs the home. A new manager has been appointed and has submitted his application for registration. Staff said that the new manager had made a lot of improvements and people living in the home are benefited from this. He is clearly committed to making sure that people get the care they need and are supported in having a good quality of life. The home has appointed an activities organiser and there has been a noticeable improvement in how people’s social care needs are addressed. People have the opportunity to take part in a variety of group and individual activities, for example one person spoke enthusiastically about the tomato and sunflower plants he is growing. There are also more opportunities for people to go out. The gardens have been tidied up and a bench has been provided so that people are now able to sit outside if they choose. Recruitment procedures have improved. All the required are completed before new staff start work and this reduces the risk to people living in the home. Improvements to the environment are continuing to make sure that the home provides a pleasant, clean, and comfortable place for people to live. 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. Pollard House DS0000056120.V335359.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 Pollard House DS0000056120.V335359.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. Information is available to help people decide if the home is suitable for them and people’s needs are assessed before they are offered a place. EVIDENCE: The Statement of Purpose and Service User guide have been updated. They are readily available to people in the home. A large print version is available on request. There had been one admission since the last inspection. The acting manager and the deputy manager carried out a detailed pre-admission assessment to find out about the person’s needs before a place was offered. There was a review 2 weeks after admission to discuss how the person was settling in. There were signed contracts in the records looked at. Three of the four people living in the home who completed comment cards said they had contracts. Pollard House DS0000056120.V335359.R01.S.doc Version 5.2 Page 9 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. People’s personal and health care needs are met and the care records are continuing to improve to help make sure that care is delivered in a way that is consistent and takes account of people’s wishes. EVIDENCE: I looked at two people’s care records. The home is still working to improve the care records to make sure that they give a clear picture of people’s needs. Generally, there is information on how people’s personal, health, and social care needs will be met. All the staff are doing training on care planning. The home works closely with the community district nursing team to make sure that health care needs are met. When people need special equipment, for example to reduce the risk of developing pressure sores, the district nurses arrange this. District nursing staff said the home keeps them informed about changes in people’s health care needs and follows the clinical advice they give. Pollard House DS0000056120.V335359.R01.S.doc Version 5.2 Page 10 When people need to be referred to specialists, for example a dietician, this is arranged either by the GP or the district nurses. Overall, people living in the home were satisfied that they got the care and support they needed. One person said the home always keeps him informed about his relative’s care. People’s changing needs are identified and the management team understand that this will sometimes mean people will have to be supported in finding more suitable accommodation in a home that provides nursing care. Medicines are stored safely and the records relating to the administration and management of medicines were up to date and accurate. Staff are receiving training on the safe management of medicines. Pollard House DS0000056120.V335359.R01.S.doc Version 5.2 Page 11 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. There are opportunities for people to take part in a variety of group and individual activities. The home is continuing to develop the range of activities provided to take account of people’s interests and needs. EVIDENCE: The home has appointed an activities organiser. She has started to gather information on people’s interests and hobbies so that she can arrange suitable activities. The activities records are detailed and include information on what people enjoyed and what they didn’t. The records show that people have played indoor bowls, done jigsaws, joined music groups and sing a longs and gone for walks to the local shops. They also show that she is spending time with people who do not like group activities talking to them about their past lives and in one case playing card games. Bingo and quizzes are held every week and there is an exercise session once a fortnight. A mobile library service now visits and people can borrow books and Pollard House DS0000056120.V335359.R01.S.doc Version 5.2 Page 12 videos. One of the televisions has some satellite channels, one person likes to watch science fiction programmes and others enjoy watching old films. The home has started to produce a newsletter and this has information about activities. The home has one person of Polish origin and they have arranged for her to continue going to the Polish club every week. They have a list of Polish phrases to help with communication because this lady speaks very little English. There is some good information in the care plans about how to understand non-verbal communication. They have made contact with an interpreter who will visit the home if necessary. They have also made some changes to the menu to cater for her dietary preferences, for example by providing soup at the start of meals. Daily routines are flexible; people are free to choose whether to stay in their rooms or to use the communal rooms. Some people go out alone and others go out with family. Most people were happy with the food; one person said that since the new cook has started there is more variety for people on diabetic diets. The meal on the day I visited looked appetising and people said they enjoyed it. When necessary people were encouraged or helped with their meals. Pollard House DS0000056120.V335359.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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 using the service can be confident that any concerns they have will be listened to and taken seriously. People are protected from abuse. EVIDENCE: Information on how to make a complaint is included in the Statement of Purpose and Service User guide and there are copies of these documents in every bedroom. Generally people living in the home were aware of how to raise concerns, one person said they never had anything to complain about. One relative said the home always responded appropriately if they had any concerns. We have not received any complaints since the last inspection. The home has recorded 12 complaints since the last inspection; the majority of these were from people living in the home. This demonstrates they have confidence in the complaints procedures. All were dealt with appropriately and responded to within 28 days. The records show details of the complaint and the action taken. The majority of staff have attended adult protection training, this is also included in induction training for new staff. Staff are aware of people’s rights. They know the correct procedures to follow when incidents happen and they Pollard House DS0000056120.V335359.R01.S.doc Version 5.2 Page 14 make sure that other agencies such as the Police or Adult Protection are informed. Pollard House DS0000056120.V335359.R01.S.doc Version 5.2 Page 15 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 & 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. The home is clean and comfortable. The owners continue to make improvements to make sure that people live in a safe and pleasant home that is suitably equipped to meet their needs. EVIDENCE: Since the last inspection the garden has been tidied and there is a bench if people want to sit outside. It is now a nice place for people to sit. Tidying up the garden has made it easier for people to use the path, but is still uneven. The acting manager said this would be resolved if the planning application is approved. The home has applied for planning permission to build an extension. The home was clean and tidy when I visited and people said it usually is. There was an odour in one bedroom; staff were aware of this and dealing with Pollard House DS0000056120.V335359.R01.S.doc Version 5.2 Page 16 it. A new carpet cleaner has been provided to help keep the home clean and free of unpleasant odours. People’s rooms are suitably furnished and some people have lots of their personal belongings around them. People can have keys to their rooms if they wish. There is a passenger lift, which provides easy access to all floors, and there is a stair lift from the ground floor to the top floor. New flooring has been fitted in some toilets and bathrooms and they look cleaner as a result. There has been no change to the provision of assisted bathing facilities; the home currently has one assisted bath and one disabled access shower. The owner is aware that this needs to be addressed. The television has been removed from one of the communal rooms on the ground floor so that there is now a quiet place for people to sit. The home has a designated smoking area on the lower ground floor. Risk assessments have been done for people who smoke in their bedrooms, the acting manager said he was aware this would have to be reviewed with the smoking ban becomes effective in July 2007. The home has been awarded a four star rating (the maximum is five) by Environmental Health for the standards of food safety and hygiene. The person working in the laundry was not wearing gloves or an apron; this increases the risk of cross infection. Pollard House DS0000056120.V335359.R01.S.doc Version 5.2 Page 17 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. Generally there are enough staff available and training has improved which means that staff are better equipped to meet people’s needs. Good recruitment procedures mean that people are protected. 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. The activities organiser works approximately 20 hours a week and separate staff are employed for housekeeping and cooking. Generally people were satisfied that staff were available when needed and that staff listened to them and took notice of what they said. The home is in the process of recruiting 2 senior care assistants. The night duty rota is being changed to make that there is always a senior care assistant on duty. I looked at the files of three newly appointed staff. The records showed that all the required checks had been completed before new staff started work. These included PoVA (Protection of Vulnerable Adults) and CRB (Criminal Pollard House DS0000056120.V335359.R01.S.doc Version 5.2 Page 18 Record Bureau) checks, two written references and proof of eligibility to work in the UK. The home has its own induction checklist and care staff also do the Skills for Care induction standards. These are nationally recognised standards covering subjects such as the confidentiality, adult protection and health and safety and are designed to make sure new staff are helped to get the knowledge and skills they need to care for people properly. Information provided by the home showed that 50 of care staff have gained an NVQ (National Vocational Qualification) level 2. Two more staff are doing NVQ training. Each staff file now has a training record and these showed that since the last inspection staff have received moving & handling training. All staff are doing training on care planning. The home is using distancelearning packages for some training such as dementia care and the safe management of medicines. Pollard House DS0000056120.V335359.R01.S.doc Version 5.2 Page 19 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, 35, 36, 37 & 38 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. The management team continue to make improvements. There are systems in place to make sure that people are consulted and that the health and safety of people living and working in the home are protected. EVIDENCE: The acting manager who has been in post for approximately 6 months has applied for registration. He has no previous experience of caring for older people and is aware he will have to get qualifications in care and management. He has a very “hands on” approach, staff said he listens to them and “he gets things done.” Pollard House DS0000056120.V335359.R01.S.doc Version 5.2 Page 20 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 March and May 2007; the topics discussed included activities, menus, and smoking rules. There has been one staff meeting since the last inspection. Questionnaires were sent to people who use the service in April 2007. Most of the responses were positive, one person said “always met with a smile and offered a cup of tea” another said staff are “helpful and caring”. Some person raised an issue about the laundry and this was followed up and dealt with. The home holds small amounts of personal money for some people. The records were looked at in January 2007 and were accurate and up to date; they were not checked on this visit. The owner does a random check as part of the monthly visit and relatives are asked to check them from time to time. The records relating to maintenance were readily available and up to date. Staff supervision was recorded in the staff files. The registration certificate and current insurance certificate are displayed. Pollard House DS0000056120.V335359.R01.S.doc Version 5.2 Page 21 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 3 3 X X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 X X 3 X 2 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 3 3 X 3 3 3 3 Pollard House DS0000056120.V335359.R01.S.doc Version 5.2 Page 22 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 OP21 Regulation 23 Requirement There must be enough suitably equipped baths/showers to make sure that people have easy access to suitable bathing facilities. This is carried forward from the last inspection. 2 OP26 13(3) Staff working in the laundry must use personal protective equipment such as gloves and aprons to reduce the risk of cross infection. Previous timescale of 31/10/06 & 30/03/07 not met. 31/10/07 Timescale for action 31/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Pollard House DS0000056120.V335359.R01.S.doc Version 5.2 Page 23 No. 1. 2. Refer to Standard OP14 OP15 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. Complaints should be recorded using a loose-leaf format – this will make it easier to keep all the related documents together and to protect confidentiality. The format used for recording accidents/incidents should be improved. An audit of all accidents should be done at least once a month. 3. 4. 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