Inspection on 24/08/05 for Pollard House

This inspection was carried out on 24th August 2005.

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 16/01/07

Pollard House 13/06/06

Pollard House 26/01/06

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 BD2 4RW Lead Inspector Mary Bentley Unannounced 24 August 2005, 09.45am th 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 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 J52 J03 S56120 Pollard House V242197 240805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Pollard House Address 68 Pollard Lane Undercliffe Bradford BD2 4RW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01274 636208 Mr Chander Shekher Kainth Care Home Only 28 Category(ies) of Dementia Over 65 (10) Physical Disability Over registration, with number 65 (2) Old Age (10) of places Pollard House J52 J03 S56120 Pollard House V242197 240805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection August 2004 Brief Description of the Service: Pollard House is an adapted Victorian building providing accommodation for twenty-eight service users. The special needs of those in occupancy are physical disabilities and/or dementia related illnesses. There is one lounge on the lower ground floor, with two lounges and a dining room on the ground floor. There are bathrooms, assisted showers and toilets on each floor near to lounges and bedrooms. There are gardens to both the front and rear of 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 rear of the building with additional roadside parking. Pollard House J52 J03 S56120 Pollard House V242197 240805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection year runs from April to March and within that time, the CSCI is required to carry out a minimum of two inspections of all care homes. This was the first inspection of the home for this inspection year. The inspection was unannounced and was carried out by one inspector who spent approximately six hours in the home. Before the visit time was spent planning how the inspection would be carried out. The purpose of this inspection was to assess the performance of the home against a pre-determined selection of the National Minimum Standards for Older People and to investigate a complaint. A summary of the complaint investigation report can be requested from the CSCI Rodley office. The methods used in this inspection included discussions with the residents, staff and management, examination of records, observation of care staff carrying out their duties and tour of the home. Comment cards were left at the home to be given to residents and relatives these cards provide an opportunity for people to share their views of the home with the CSCI. Comments received in this way will be shared with the provider without revealing the identity of the respondents. The CSCI has so far received one comment card from a resident; this said that the resident was happy with all aspects of life in the home. What the service does well: What has improved since the last inspection? Some progress has been made on the requirements and recommendations made at the last inspection. The double-glazing units have been replaced and the programme of NVQ (National Vocational Qualification) training is ongoing. A training and development programme for staff has been done. Pollard House J52 J03 S56120 Pollard House V242197 240805 Stage 4.doc Version 1.40 Page 6 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. Pollard House J52 J03 S56120 Pollard House V242197 240805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Pollard House J52 J03 S56120 Pollard House V242197 240805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 & 3. Standard 6 does not apply to this home. The terms and conditions do not set out clearly what services and facilities the home will provide and what is included in the fees. The needs of prospective residents are assessed before they are admitted to the home. EVIDENCE: Copies of signed terms and conditions of residency were seen in the care files looked at, however some of the information was not clearly presented, for example the acting manager said that televisions were provided in bedrooms on request but this was not clearly stated in the contract. A pre admission assessment had been done for a resident recently admitted to the home. A requirement has been made about one of these standards. Pollard House J52 J03 S56120 Pollard House V242197 240805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 The personal care needs of residents are met and their privacy and dignity are respected. The home has good working relationships with community nurses who support them in making sure that health care needs are met. EVIDENCE: The complaint received by the CSCI raised concerns about personal and health care needs. Three sets of care records were seen and they showed that care plans are available setting out how personal and health care needs will be met. There is little or no information about how social care needs will be dealt with. The care plans were reviewed monthly and showed that residents and/or their representatives are involved in care planning. The records showed that the behaviour of one resident was causing some problems and a care plan was not available to guide staff on how to manage this. District Nurses support the home in meeting health care needs. The correct equipment had been provided and was in use for one resident identified as being at high risk of developing pressure sores. Pollard House J52 J03 S56120 Pollard House V242197 240805 Stage 4.doc Version 1.40 Page 10 Residents looked well cared for and those spoken with said they felt well cared for. The complaint raised concerns about the management of residents with diabetes, senior care staff have been trained by the District Nurses to give insulin, the records for this were accurate. The records also showed that blood sugar levels are checked in accordance with the instructions given by the District Nurses. Nutritional needs are assessed and records of monthly weights were available. The records of controlled drugs were not accurate; medicines that had been returned were not properly accounted for. Senior care staff are aware of the correct action to take if there are medication errors. Requirements have been made about two of these standards. Pollard House J52 J03 S56120 Pollard House V242197 240805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 & 15 The rights of residents who are able to exercise choices are respected but there is very little opportunity for less able residents to engage in social and recreational activities. EVIDENCE: The complaint received by the CSCI referred to a lack of activities. There is no programme of activities for residents. The owner said he was aware this needed to be addressed and was recruiting an activities organiser. Televisions were on in all three communal rooms used by residents and there was no sign of any other activity. One resident goes out regularly with his family and another resident is able to go out independently but other residents who are less able said there was nothing much to do. Residents were seen to spend their time either in their rooms or in one of the communal areas. The complaint referred to lack of privacy for visits. Residents said they could receive visitors in private but most seemed content to see their visitors in the communal areas. One resident was seen to receive a visitor in private. Residents said the food was good and there was plenty of it and they are given a choice, on the day of the inspection two residents said their lunch was cold. Pollard House J52 J03 S56120 Pollard House V242197 240805 Stage 4.doc Version 1.40 Page 12 Residents can have their meals in their rooms if they choose not to use the dining room. Requirements and recommendations have been made about these standards. Pollard House J52 J03 S56120 Pollard House V242197 240805 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The complaints procedure is widely available and this supports the rights of residents and/or their representatives to raise any concerns they might have. EVIDENCE: The home keeps a complaint book and no complaints have been recorded since the last inspection. One aspect of the complaint received by the CSCI was that the home had not responded to concerns but the owner and acting manager said that they had not been informed of any concerns. The complaints procedure is displayed in the home and included in the Statement of Purpose and Service User guide. Residents said they knew who to speak to if they had any concerns. Pollard House J52 J03 S56120 Pollard House V242197 240805 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 24, 25 & 26. The environment that residents live in is generally comfortable and safe however some improvements are needed to make sure that acceptable standards are maintained. A number of bedrooms had a distasteful smell creating an unpleasant environment for those residents. Some working practices create the opportunity to put residents at risk from cross infection. EVIDENCE: The home had an environmental health inspection in April 2005; the acting manager said that all the points raised had been dealt with. There is plenty of communal space with two lounges and a dining room on the ground floor and a smoker’s lounge on the lower ground floor. One of the lounges has a nice outlook over the golf course. The dining room carpet and corridor floor covering were in need of replacement; the owner said he was dealing with this. The fire exit door on the first floor does not have an alarm fitted therefore staff would not be aware if a resident wandered out onto the fire exit. Pollard House J52 J03 S56120 Pollard House V242197 240805 Stage 4.doc Version 1.40 Page 15 Some of the rooms seen had an unpleasant odour. In one bedroom a roof leak had damaged the wall and ceiling, the roof has been repaired but the bedroom had not been redecorated. A number of other bedrooms needed decorating and new furniture. In some of the rooms seen residents had their personal belongings around them. Door locks are fitted to all bedroom doors but they are not “single action” locks. There were televisions in some rooms, the acting manager said televisions were provided on request but this was not clear from the terms and conditions of residency. The complaint referred to a resident not wearing his own clothes, the clothing seen was marked with the identity of the people to whom it belonged. Some clothing was named using marker pen and this is not good practice, the best way to name clothing is to sew on nametags. The laundry equipment is adequate however the owner said new commercial machines were to be purchased soon. Bars of soap were seen in most of the communal toilets and bathrooms; this increases the risk of cross infection. Some of the towels seen were worn thin. The owner said that hot water temperatures are regulated with thermostatic valves and that water temperatures are checked monthly, there are no records of these checks. Requirements and recommendations have been made about some of these standards. Pollard House J52 J03 S56120 Pollard House V242197 240805 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 & 29 The numbers and skill mix of staff meets residents’ needs. To assure the protection of residents robust recruitment procedures must be followed consistently. EVIDENCE: Residents were satisfied that there were enough staff to meet their needs and many said that staff were “very good”. Two senior care staff recently left, the home is now advertising to fill these vacancies, in the meantime agency staff are used to make sure there are enough staff on duty to care for residents. 25 of care staff have an NVQ (National Vocational Qualification) level 2. A further five staff are registered on this qualification. One member of staff has done dementia training; there are plans for another six staff to attend this training. The files of two recently appointed staff were seen, in one file the required CRB (Criminal Records Bureau) check or POVA (Protection of Vulnerable Adults) had not been done by the home before the person started work. Requirements have been made about two of these standards. Pollard House J52 J03 S56120 Pollard House V242197 240805 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35, 37 & 38. Residents’ financial interests are safeguarded. The lack of fire training creates the opportunity for residents and staff to be exposed to unnecessary risk. EVIDENCE: The acting manager is a registered nurse and is doing the registered managers award. The law requires managers of care homes to be registered by the CSCI; an application for her to be registered has not been made. The complaint raised concerns about the management of one resident’s finances by the home; the investigation found no evidence of financial irregularities. Photographs were not available for all residents. One resident had bed rails fitted, a risk assessment had not been completed. Pollard House J52 J03 S56120 Pollard House V242197 240805 Stage 4.doc Version 1.40 Page 18 Checks on fire safety systems are carried out regularly. The fire drill records do not have enough information about how the drill was carried out. The training records show that no fire training has taken place this year. The deputy has attended an approved training course that allows her to do fire training. Both cooks have done Basic Food Hygiene training. Three staff have done first aid training. Moving and handling training is up to date; the acting manager is trained to provide this training. Some requirements have been made about these standards. Pollard House J52 J03 S56120 Pollard House V242197 240805 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 3 x x N/A 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 x 15 3 COMPLAINTS AND PROTECTION 2 3 x x x 2 3 2 STAFFING Standard No Score 27 3 28 2 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 x x x 3 x 2 2 Pollard House J52 J03 S56120 Pollard House V242197 240805 Stage 4.doc Version 1.40 Page 20 Yes Are there any outstanding requirements from the last inspection? 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 2 Regulation 5(1)(b) & (c) Requirement The terms and conditions must set out clearly what services and facilties are provided and whether or not these are included in the fees. The service users plans must set out in detail how personal, health and social care needs will be met. The registered persons must make sure that the records relating to controlled drugs are kept up to date and accurate. The registered persons must consult with service users about the programme of activities and provide facilities for recreation. All areas of the home must be kept in a good state of repair. Furnishings and decoration must be maintained to a reasonable standard. All parts of the home must be kept free of offensive smells. The practice of using bars of soap in communal toilets and bathrooms must stop. 50 of care staff must be qualified to NVQ level 2 or equivalent. J52 J03 S56120 Pollard House V242197 240805 Stage 4.doc Timescale for action 30 November 2005 28 October 2005 28 October 2005 28 October 2005 30 November 2005 28 October 2005 2. 7 15 3. 9 13(2) 4. 12 16(2)(n) 5. 19 23(2)(b) & (d) 6. 26 16(2)(k) 13(3) 7. 28 18 31 December 2005 Page 21 Pollard House Version 1.40 8. 29 19 Carried forward from the last inspection. New staff must not start work in the home until CRB and POVA checks have been done. Previous timescale of 31/12/04 not met. An application must be made to the CSCI for the acting manager to be registered. The owner must carry out visits in accordance with the requirements of this regulation and provide copies of the reports of these visits to the CSCI. Carried forward from the last inspection. The home must have a photograph of every service user. A risk assessment must be done for bed rails in use and they must be maintained in safe working order. All staff working in the home must have fire safety training at least twice a year. 21 September 2005 9. 10. 31 32 8&9 26 30 September 2005 30 September 2005 11. 12. 37 38 17(1)(a) 13(4)(b) & (c) 23(4) 28 October 2005 30 September 2005 30 September 2005 13. 38 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 13 15 19 24 Good Practice Recommendations Staff in the home should be more proactive about offering facilities for visits to take place in private. Hot meals should be served at the correct temperature. An audible alarm should be fitted to the fire exit door on the first floor identified during the inspection. As and when the home is refurbished the existing door locks should be replaced with single action locks. J52 J03 S56120 Pollard House V242197 240805 Stage 4.doc Version 1.40 Page 22 Pollard House 5. 6. 25 26 The home should keep records of the checks done on hot water temperatures. The practice of naming clothing with marker pen should be discontinued, clothing should be named using sew on nametags. The worn towels should be replaced. Pollard House J52 J03 S56120 Pollard House V242197 240805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Pollard House J52 J03 S56120 Pollard House V242197 240805 Stage 4.doc Version 1.40 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!