Inspection on 21/06/06 for Vishram Ghar

This inspection was carried out on 21st June 2006.

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 18/10/05

Vishram Ghar 27/06/05

Similar services:

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 Debbie Williams Unannounced Inspection 21st June 2006 12:00 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.V300278.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. Vishram Ghar DS0000063114.V300278.R01.S.doc Version 5.2 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 Ms Kusum Vala 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.V300278.R01.S.doc Version 5.2 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 18th October 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 en suite facilities and one double bedroom without en suite facility. A garden is situated to the rear of the premises. At the time of this inspection, the range of fees was from £340 per week to £385 per week. Vishram Ghar DS0000063114.V300278.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The main method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. The inspection was facilitated by the Registered Manager, the inspector also spoke with care staff. This was a positive inspection as it was evident that all three case tracked residents were satisfied with the care they received and that their needs were being met. 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? Refurbishment of the kitchen and dining rooms is near completion. New documentation has been introduced with regard to assessment and care planning records, once this is fully implemented this will provide a more comprehensive record of residents needs. Since the last inspection the manager has become registered with the Commission for Social Care Inspection. Vishram Ghar DS0000063114.V300278.R01.S.doc Version 5.2 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. Vishram Ghar DS0000063114.V300278.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 Vishram Ghar DS0000063114.V300278.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. It was evident that the care provided met the needs of case tracked residents accommodated, however there was very little assessment information recorded for one resident which could lead to needs not being met. EVIDENCE: Assessment records were seen for three case tracked residents. A new system of documentation was being introduced and where this was used a comprehensive assessment of residents needs was available. However there was very little information available for one resident despite obvious complex needs and risk of falling as identified within the social worker assessment. Where applicable social work assessments were in place. Vishram Ghar DS0000063114.V300278.R01.S.doc Version 5.2 Page 9 The home cares for older people who may have physical disabilities in an Asian lifestyle environment. Case tracked residents chose the home specifically because of the Asian lifestyle environment Vishram Ghar DS0000063114.V300278.R01.S.doc Version 5.2 Page 10 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): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Health and personal care needs are met and medication procedures minimise risk. EVIDENCE: Care plans were in place for all case tracked residents, for one resident, information was very basic despite a number of needs identified within the social worker assessment. A new system of documentation was being introduced and where this was used, provided a much more comprehensive record of residents needs. Daily records appeared accurate and described the events of the day and general wellbeing of the residents clearly. They also provided evidence of GP and community nurse visits as well as hospital appointments. The GP who provides care to all residents in the home holds a surgery at the home on a weekly basis. Residents spoken with felt they were enabled to access all necessary health care services. Medication administration records for case tracked residents were inspected and all appeared accurate and in good order. Controlled medication storage areas and records of administration were also checked and found to be correct. Controlled medication is stored separately and securely. Two sets of staff initials were Vishram Ghar DS0000063114.V300278.R01.S.doc Version 5.2 Page 11 seen against each record of administration. The registered manager said that only senior care assistants administer medication and only once she is satisfied they are competent following a period of supervision, however there is no record of this training and assessment ant staff do not receive any accredited medication training. The home has a contract with a pharmacist and plans are afoot for training to be provided. Interaction between staff and residents observed during this inspection appeared positive, appropriate and respectful. Records of staff induction training were not available for inspection but the registered manager said that induction training is provided to all new staff. Residents spoken with gave high praise to staff members and confirmed they were treated with dignity and their privacy respected at all times. Vishram Ghar DS0000063114.V300278.R01.S.doc Version 5.2 Page 12 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): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are able to exercise autonomy and choice and have their individual needs met. EVIDENCE: Case tracked residents felt that routines of daily living were flexible and met their individual needs. Visitors are made welcome in the home and can be seen in private. Menu records seen provided a choice of meals and catered for specific cultural/religious needs. The home is undergoing a programme of refurbishment there will be two new dining rooms and one new kitchen, this will enable the provision of entirely separate non vegetarian and vegetarian food preparation and dining. These were seen by the inspector, they are near to completion and appeared to be of a very good standard. Residents were happy with the menu and meals provided. Vishram Ghar DS0000063114.V300278.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Vulnerable adult policy and procedures minimise risk for residents. EVIDENCE: The manager said that no complaints had been received and therefore no complaint records maintained. Residents spoken with said they would feel comfortable making a complaint if the need arose. The Registered Manager when asked what action she would take in the event of suspected abuse was not entirely clear of the correct procedure to follow in line with local policy ‘no secrets’. One staff member spoken with had previously received adult protection training but not while working at Vishram Ghar. Vishram Ghar DS0000063114.V300278.R01.S.doc Version 5.2 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 the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The premises appeared homely comfortable and safe. While some areas required decorative attention, a programme of redecoration was underway. EVIDENCE: Communal areas and the private accommodation of case tracked residents were seen during this inspection. A programme of refurbishment and redecoration was in place. The registered manager said that all areas of the home would be redecorated. Residents spoken with said they were happy with the premises and with the standard of maintenance and cleanliness. One staff member spoken with had received infection control training. Vishram Ghar DS0000063114.V300278.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Staff are provided in sufficient numbers and skill mix to meet the needs of residents accommodated. Recruitment procedures minimise risk to residents. EVIDENCE: Residents and staff spoken with felt that sufficient numbers of staff were provided and they were competent to carry out their jobs. A selection of training certificates was seen. The registered manager said National Vocational Qualification training would be introduced later in the year. Staff were currently receiving training in caring for residents with dementia as the providers planned to become registered for this category. Staff records were unavailable for inspection as the registered manager did not have a key to access these records, therefore staff files could not be inspected for reference, Criminal Records Bureau checks, induction and supervision. The inspector spoke with the registered provider and asked that these records be available for inspection at all times and to provide written confirmation that all staff employed have relevant Criminal Records Bureau checks and references in place. Vishram Ghar DS0000063114.V300278.R01.S.doc Version 5.2 Page 16 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): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Management and administration procedures in place promote the best interests of residents. EVIDENCE: The registered manager was registered with the CSCI earlier this year. Residents and staff spoken with found the management structure open and inclusive. There was no programme of quality assurance in place. Records of all transactions regarding resident’s personal money are maintained and appeared in good order. Records of staff training with regard to moving and handling, fire safety and general health and safety were seen. Vishram Ghar DS0000063114.V300278.R01.S.doc Version 5.2 Page 17 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 x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 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 2 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 3 Vishram Ghar DS0000063114.V300278.R01.S.doc Version 5.2 Page 18 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 OP29 Regulation 17 Requirement The Registered persons shall ensure that the records referred to in paragraphs 1 and 2 (Regulation 17 (3) staff records) are at all times available for inspection in the care home by any person authorised by the commission to enter and inspect the care home. Timescale for action 21/06/06 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 Refer to Standard OP3 OP9 Good Practice Recommendations It is recommended that assessment records contain all the information required for staff to meet residents health, personal, social and cultural needs. It is recommended that a written record is maintained of all training, supervision and assessment provided to staff regarding the safe handling, storage and administration of medication and that further accredited training be provided. DS0000063114.V300278.R01.S.doc Version 5.2 Page 19 Vishram Ghar 3 1OP18 4 OP33 It is recommended that the Registered Manager has a full working knowledge of the vulnerable Adults Policy ‘No Secrets’ and that further training regarding the protection of vulnerable adults is provided to all care staff. It is recommended that a programme of quality assurance be implemented. Vishram Ghar DS0000063114.V300278.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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.V300278.R01.S.doc Version 5.2 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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