Inspection on 27/06/05 for Vishram Ghar

This inspection was carried out on 27th June 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 18/10/05

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 124 Armadale Drive Netherhall Leicester LE5 1HF Lead Inspector Everton Osbourne Unannounced 27 June 2005 09:30 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. Vishram Ghar C51 C01 S63114 Vishram Gar V234095 270605 STAGE 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Vishram Ghar Address 120 Armadale Drive Netherhall Leicester LE5 1HF 0116 2419584 0116 2432745 None BestCare Limited 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) N/A Care Home 40 Category(ies) of OP Old Age (40) registration, with number PD Physical Disability(40) of places PD(E) Physical Disability - over 65(40) Vishram Ghar C51 C01 S63114 Vishram Gar V234095 270605 STAGE 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1) No persons under 55 years of age falling, within category PD may be admitted to the home. Date of last inspection 5th October 2004 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 C51 C01 S63114 Vishram Gar V234095 270605 STAGE 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took five hours and thirty minutes to complete. With the exception of one Immediate Requirement made concerning safe storage of cleaning chemicals, the outcome of the inspection was positive. Three residents spoken to indicated that they are satisfied that the home is meeting their care needs. The previous owners ASRA Midlands Housing Association sold the home to Best Care Limited in March 2005. A programme of refurbishment is currently ongoing for maintenance purposes and to further create a homely environment. Two staff members were spoken with as part of the inspection process. The acting manager and one of the proprietors were also spoken to. 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 C51 C01 S63114 Vishram Gar V234095 270605 STAGE 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Vishram Ghar C51 C01 S63114 Vishram Gar V234095 270605 STAGE 4.doc Version 1.30 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 standard(s) 1, 2, 3 and 4 The provider’s assessment process is good and the admission procedure effective in ensuring that residents receive appropriate care in the right environment. EVIDENCE: The Statement of Purpose seen had adequate information about the services provided in the home. Two residents’ care records seen had a copy of this document. Two residents’ admission records seen indicated that a contract of residence is given to them outlining the Terms and Conditions of their residency in the home. Two residents spoken with gave clear indications that they understood their Terms and Conditions of residency in the home. Two residents’ assessments were examined. The documents clearly identified the care needs of the residents. The two residents indicated that they are satisfied that the care needs identified in the assessments matched their care needs. With the use of an interpreter, one resident commented ‘Very good, very kind staff’. Vishram Ghar C51 C01 S63114 Vishram Gar V234095 270605 STAGE 4.doc Version 1.30 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 standard(s) 7, 8, 9 and 10 The care plan process is effective in ensuring that residents’ social and health care needs are met appropriately. Medication is managed well so that residents receive their prescribed dose of medication. EVIDENCE: Two residents’ care plans were examined. The documents contained good and sufficient information in order to give staff members’ guidance on how to meet residents’ care needs. Through an interpreter, both residents indicated that they are satisfied with the care given by the care staff and that residents are treated with respect. The residents spoken with indicated that they have access to their General Practitioner and Community Nurse when needed. Their health care records seen and discussion held with the acting manager indicated that a weekly doctor’s surgery is held to attend to residents’ medical care needs. The medication process was observed during the inspection. The process was carried out safely. Two residents’ medication records seen indicated that appropriate record keeping is being maintained. The medication policy contains adequate information for staff members’ safe medication practice. Vishram Ghar C51 C01 S63114 Vishram Gar V234095 270605 STAGE 4.doc Version 1.30 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 standard(s) 12, 13, 14 and 15 Giving residents’ choice over their daily lives and providing good quality meals is managed well for residents residing in the home. EVIDENCE: One resident spoken with indicated that meals are varied and wholesome and that daily choice is given. With the use of the interpreter, the resident commented ‘Meals are very good’. The menu and lunchtime meal seen confirmed the residents’ verbal statement. Discussion held with one kitchen staff member indicated that specialist meals are provided for example meals for residents with diabetes. One resident spoken with confirmed the kitchen staff member’s verbal statement. Two residents spoken with indicated that they maintain contact with relatives and friends and that they are able to make visits away from the home. Visitors’ records seen indicated that the home receives visitors on a regular basis. One resident indicated through the interpreter that visitors are treated very well, for example receiving a good welcome, meals and drink if needed. Vishram Ghar C51 C01 S63114 Vishram Gar V234095 270605 STAGE 4.doc Version 1.30 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 standard(s) 16 and 18 Robust processes are in place so that residents or their relatives can make a complaint if required. There is an adult protection procedure in place to respond to suspicion or allegation of abuse for residents’ protection. Insufficient precaution has the potential of placing residents at risk regarding an unsecured cleaning cupboard with cleaning chemicals. EVIDENCE: An examination of the complaint process indicated that guidance is given to residents and their relatives on how to make a complaint. One resident spoken with indicated that the complaint process was explained on arrival in the home. The adult protection process was inspected. Clear guidance is written for staff members regarding protecting vulnerable adults. Two staff members spoken with gave good verbal responses regarding their understanding concerning reducing the risk of elder abuse and what actions to take in the event of suspicion or allegation of abuse. A cleaning cupboard containing cleaning chemicals hazardous to health situated along residents’ corridor had an unsecured door. The door was closed but not key locked for residents’ safety. Clear signs are written on the door indicating that this room should be key locked at all times. At the time of the inspection the acting manager made the room secure for residents’ safety. An Immediate Requirement Notification was issued requiring the home to keep the cleaning store room key locked at all times for residents’ safety. Vishram Ghar C51 C01 S63114 Vishram Gar V234095 270605 STAGE 4.doc Version 1.30 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 standard(s) 19, 21, 22 and 26 The home is being maintained to good standards with an emphasis on creating a homely environment. Adequate communal space and facilities are provided for residents’ comfort. EVIDENCE: A programme is currently ongoing to refurbish the whole premises. Discussion held with the owner and acting manager indicated that the refurbishment will be completed over a period of six months. The bathroom and toilet facilities were inspected and found to be sufficient in numbers based on the number of residents residing in the home. An inspection of the premise found it to be clean and hygienic. Observation of care practices made and discussions held with two care staff members indicated that staff members appear to be adhering to good hygiene practice for example good hand washing techniques. Vishram Ghar C51 C01 S63114 Vishram Gar V234095 270605 STAGE 4.doc Version 1.30 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 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 The number of staff employed to work in the home is sufficient in meeting residents’ assessed care needs. EVIDENCE: The staffing rota was examined and a physical count indicated that there was adequate numbers of care staff on duty. The staffing rota seen and discussion held with the acting manager indicated that there is appropriate skill mix of staff employed to work in the home. One resident spoken to indicated that a staff member is always available when needed. Vishram Ghar C51 C01 S63114 Vishram Gar V234095 270605 STAGE 4.doc Version 1.30 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 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) 37 and 38 Residents’ care records and fire safety is well managed for residents’ protection. EVIDENCE: Two residents’ care records were inspected. All care records seen, for example the medication records are kept up to date. Observations made indicated that fire safety equipment for example fire extinguishers are examined on a regular basis. Two staff members gave good verbal responses regarding safe practices in the home, for example actions to take should there be suspicion or outbreak of fire in the home. Observation of moving and handling techniques seen indicated that the actions were carried out safely. Vishram Ghar C51 C01 S63114 Vishram Gar V234095 270605 STAGE 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 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 3 x 3 3 x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x x x 3 3 Vishram Ghar C51 C01 S63114 Vishram Gar V234095 270605 STAGE 4.doc Version 1.30 Page 15 No 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 18 Regulation 13(4)(a) Requirement The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free form hazards to their safety. In this instance, the cleaning cupboard door must always be key locked for residents safety. Timescale for action Immediate 27.06.05 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. Refer to Standard None Good Practice Recommendations Vishram Ghar C51 C01 S63114 Vishram Gar V234095 270605 STAGE 4.doc Version 1.30 Page 16 Commission for Social Care Inspection The Pavilions 5 Smith Way, Grove Park Enderby, Leicestershire 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 C51 C01 S63114 Vishram Gar V234095 270605 STAGE 4.doc Version 1.30 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. 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