Inspection on 18/10/05 for Vishram Ghar

This inspection was carried out on 18th October 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Vishram Ghar 05/01/10

Vishram Ghar 21/07/09

Vishram Ghar 05/02/09

Vishram Ghar 29/02/08

Vishram Ghar 21/01/08

Vishram Ghar 14/11/07

Vishram Ghar 10/07/07

Vishram Ghar 21/06/06

Vishram Ghar 27/06/05

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Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE Vishram Ghar 120 Armadale Drive Netherhall Leicester Leicestershire LE5 1HF Lead Inspector Mr Everton Osbourne Unannounced Inspection 10:00 18 October 2005 th 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 Vishram Ghar DS0000063114.V252439.R02.S.doc Version 5.0 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. Vishram Ghar DS0000063114.V252439.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Vishram Ghar Address 120 Armadale Drive Netherhall Leicester Leicestershire LE5 1HF 0116 2419584 0116 2432745 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) BestCare Limited Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability (40), Physical disability of places over 65 years of age (40) Vishram Ghar DS0000063114.V252439.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No person under 55 years of age, falling within category PD may be admitted to the home 27th June 2005 Date of last inspection Brief Description of the Service: Vishram Ghar care home cares for forty older persons who may have physical disabilities in an Asian lifestyle environment. The property is purpose built and is situated in the residential area of Netherhall close to shops and other facilities. The home is easily accessible for private and public transport.The premise consists of two floors accessible by use of the stairs and passenger lift. There are a variety of facilities in the home including dining and lounge space. The home comprises thirty-eight single bedrooms two with ensuite facilities and one double bedroom without ensuite facility. A garden is situated to the rear of the premises. Vishram Ghar DS0000063114.V252439.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took four hours to complete. The outcome of the inspection was positive in that two residents spoken with and observations made indicated that they are satisfied with the care provisions in the home. One of the owners, the acting manager, one staff member and one visitor to the home were also spoken with as part of the inspection process. Best Care Limited, the company that owns the home is carrying out a programme of refurbishment and have been doing so since they took over ownership of the home in March 2005. What the service does well: What has improved since the last inspection? 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. Vishram Ghar DS0000063114.V252439.R02.S.doc Version 5.0 Page 6 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 Vishram Ghar DS0000063114.V252439.R02.S.doc Version 5.0 Page 7 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 the following standard(s): 2, 3, 5 and 6 The provider’s assessment process is good and the admission procedure effective in ensuring that residents receive appropriate care in the right environment. Good contracting procedures are practiced to promote choice and give residents rights regarding their accommodation. EVIDENCE: Two residents’ admission records seen showed that contracts are given to residents, which include the Terms and Conditions of their residency in the home. Two residents spoken with indicated that they had the choice to visit the home before moving in. Discussions held with the acting manager indicated that the policy of the home is to give prospective residents a choice to visit the home. Two residents’ assessments seen indicated that good descriptions of their care needs are recorded in plain language. Conversation held with one staff member indicated that she had good knowledge of both residents’ assessed care needs. Discussion held with the proprietor indicated that the home does not provide intermediate (rehabilitation) care. Vishram Ghar DS0000063114.V252439.R02.S.doc Version 5.0 Page 8 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 the following standard(s): 7, 9 and 11 The medication and care plan processes are good in ensuring that residents receive their medication and care as required. EVIDENCE: Two residents’ care plans were inspected. The documents seen contain good instructions for staff members so that they can attend to residents’ assessed care needs. Conversation held with one staff member indicated that she had good knowledge of both residents’ care needs. Conversation held with two residents confirmed that the home is attending to their care needs. Both residents commented respectively ‘They’re very good here’. The medication process was examined. Medication records are kept up to date and staff members consistently sign the records to indicate that medication is given to residents as prescribed by a doctor. Vishram Ghar DS0000063114.V252439.R02.S.doc Version 5.0 Page 9 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 the following standard(s): 14 Residents’ choice is managed well to give residents control over their own lifestyle. EVIDENCE: Observations of staff members interacting with residents and conversation held with two residents indicated that choice is given to residents, which is also recorded in their care plans. For example staff members were seen giving residents choice concerning their meals. Vishram Ghar DS0000063114.V252439.R02.S.doc Version 5.0 Page 10 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 the following standard(s): 17 Adult protection is managed well for the rights and protection of residents residing in the home. EVIDENCE: Conversation held with two residents and their care plans seen indicated that they are able to access advocates if required and participate in the voting process. Vishram Ghar DS0000063114.V252439.R02.S.doc Version 5.0 Page 11 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 the following standard(s): 20, 23, 24 and 25 The home is being maintained to good standards creating a homely environment. Adequate facilities and shared space are available for residents’ use. EVIDENCE: Conversation held with two residents indicated that they are satisfied with the cleanliness and size of their bedrooms. One resident commented ‘The place is clean’. Two residents’ care records seen and conversation held with them indicated that they had a choice to take into the home their own personal possessions. Observations made during a tour of the home and conversation held with two residents indicated that there is sufficient water supply, heating, ventilation and lighting in the home. Vishram Ghar DS0000063114.V252439.R02.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Sufficient staffing levels are maintained for the protection of residents residing in the home. The recruitment and training procedures adopted by the home is robust for the retention of suitably trained staff members. EVIDENCE: The staffing rota was examined, which indicated that adequate skill mix and staffing numbers are employed to work in the home on a daily basis. Observations made during the inspection indicated that there were sufficient staff members on duty. Two residents spoken with indicated that they are satisfied that staff members are available throughout the day and night. One staff member’s training and recruitment record seen indicated that all relevant documentation for example two suitable references and a satisfactory Criminal Record Bureau (CRB) declaration are in the file. Training documentation seen for example course certificates and conversation held with one care staff member indicated that she regularly attends training courses for example health and hygiene training. Vishram Ghar DS0000063114.V252439.R02.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 24, 35 and 36 The home is managed very well and staff members appropriately supervised for residents’ care and protection. EVIDENCE: Discussion held with the acting manager and questionnaires seen indicated that residents and their relatives complete these forms in order to give feedback about the care delivery in the home. Conversation held with two residents and one visitor to the home indicated that services are improving on a daily basis. Documentation seen and conversation held with two residents and one staff member indicated that the acting manager creates an open and inclusive atmosphere as a result of her management style. Pre-registration documentation seen indicate that the manager is suitably experienced and qualified to manage this home. An inspection of the financial procedures indicated that residents’ relatives manage residents’ finances. Vishram Ghar DS0000063114.V252439.R02.S.doc Version 5.0 Page 14 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 x 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 3 18 x x 3 x x 3 3 3 x 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 3 3 3 3 3 3 x x Vishram Ghar DS0000063114.V252439.R02.S.doc Version 5.0 Page 15 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Vishram Ghar DS0000063114.V252439.R02.S.doc Version 5.0 Page 16 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Vishram Ghar DS0000063114.V252439.R02.S.doc Version 5.0 Page 17 - 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!