Care Home: Pollard House

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What the care home does well What has improved since the last inspection? Since the last inspection the manager has successfully completed the process of registration with us, it is a legal requirement that all managers of care services are registered with the Commission. He is doing training to develop his knowledge. Work is continuing to improve the care records. This is to make sure that each person has a detailed plan of care and that people, or those close to them, are involved in making the plan. Improvements have been made to the way information is recorded in a number of areas, including complaints and accident records. This means that information is easier to find and it is easier for the home to identify areas of good practice and areas for improvement. Changes have been made to the laundry systems to reduce the risk of cross infection. There are now housekeeping staff on duty at the weekends. This helps to make sure the home is always clean and fresh. One of the ground floor toilets has been upgraded, it is brighter, and the walls are fully tiled meaning that it is easier to keep clean. Outside the home railings have been put up and gates are soon to be fitted, this will mean that there is a secure outdoor area for people to use. What the care home could do better: We asked people what they thought the home could do better. One person said it was sometimes difficult to get through on the phone. Another person said that they would like to see staff checking the lounges more often in case people needed help. Some people living in the home would like more opportunities to go out on organised trips. The manager is already aware of this. Work is continuing to improve the environment. This includes plans to upgrade all the communal bathrooms to make them look nicer and easier for people to use. CARE HOMES FOR OLDER PEOPLE Pollard House 68 Pollard Lane Undercliffe Bradford West Yorkshire BD2 4RW Lead Inspector Mary Bentley Unannounced Inspection 16th January 2008 09:30 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.V357945.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.V357945.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) pollardhouse@hotmail.co.uk Mr Chander Shekher Kainth Mr Sohan Lal Kainth Mr Chander Mohan Kainth 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.V357945.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Dementia - Code DE (E); Physical disability - Code PD (E) and Old Age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 28 21st June 2007 2. Date of last inspection 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 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 and one has an en-suite shower. 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 January 2008 the weekly fees ranged from £329.00 to £364.70. Hairdressing and chiropody are available at an additional cost. Information about the service, including previous inspection reports, is available in the home Pollard House DS0000056120.V357945.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The inspection process included looking at the information we have received about the home since the last key inspection. We also visited the home unannounced for one day and spent approximately 8 hours there. When we last visited in June 2007 the manager had only been in post 6 months. At that time we saw that he was making improvements to the service. The purpose of this visit was to check that the improvements were continuing and that people living in the home are benefiting from the changes. During the visit we spoke to people living in the home, visitors, staff and management. We looked at various records relating to care, staff, and maintenance and looked at some parts of the building. Before the visit we sent questionnaires to 7 people living in the home, 6 relatives and a number of staff and health care professionals who have regular contact with the home. The information we get is shared with the home without identifying who has provided it. We got 18 replies and for the most part people were satisfied with the service. We asked the home to complete a self-assessment form, which they did. It was returned in good time to help us prepare for the visit. What the service does well: These are some of the comments made by people using the service: • • • • • “You always get a warm welcome by staff “ “The friendliness of the staff is excellent” “Good home cooking, clothes washed and ironed very well, homely atmosphere” “The home is obviously cleaned regularly” “I think Pollard House gives good value for money.” People said the food is good and they are given a choice of meals. People have easy access to all parts of the home; there is a passenger lift to all floors and a stair lift from the ground floor to the top floor. Pollard House DS0000056120.V357945.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can Pollard House DS0000056120.V357945.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Pollard House DS0000056120.V357945.R01.S.doc Version 5.2 Page 8 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.V357945.R01.S.doc Version 5.2 Page 9 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): 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. People’s needs are assessed before they move in and people or those close to them are involved in the assessment. This means that people can be assured the home will be able to meet their needs. EVIDENCE: Four of the five people living in the home who returned our questionnaires said they had been asked if they wanted to move into the home. Two people said they had not been able to look at the home before moving in because the arrangements had been made by Social Services. In both cases these were people coming to the home for a short stay. In both cases the home had visited the person before they moved in to find out about their needs. Another person told us her family had visited and chosen the home for her, she is happy with the decision they made. Pollard House DS0000056120.V357945.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 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 in a way that respects their individuality and takes account of their wishes. EVIDENCE: Eight of the ten people who completed a questionnaire sent out by the home in September 2007 rated the quality of care as good or excellent. One person said “I have no concerns about the quality of care, any requests are dealt with quickly” and another said, “Staff respect the people they care for”. We looked at three people’s care records. Each person has a “pen picture” giving information about their personal, health and social care needs. This includes information on people’s interests, preferences, and areas of risk for example if someone is at risk of falling. The pen picture is used to develop a plan of care setting out how the person’s needs should be addressed day to Pollard House DS0000056120.V357945.R01.S.doc Version 5.2 Page 11 day. Some of these plans are more detailed than others and the manager is working to make sure that everyone has a detailed plan of care. The records showed that people have chiropody, eye tests, and dental care. Visits from GPs and district nurses are recorded. There are risk assessments in place to show if people are at risk for example of developing pressure sores. When risks to people’s health care are identified the home works with the district nurses to address these risks. There are satisfactory systems in place to make sure that people’s medicines are managed safely. People’s right to privacy is respected and care is given in a way that maintains people’s dignity and helps to promote independence. Pollard House DS0000056120.V357945.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. 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. People are supported in following their personal interests and in making the most of their abilities. People are able to keep in touch with family, friends, and representatives. People have nutritious and attractive meals and snacks. EVIDENCE: People’s care records have information on what they are interested in and how they prefer to spend their time. Daily routines are flexible and people told us they could decide how and where to spend their time. We saw evidence of this during the visit. One person said “At the moment I go to the day centre each Monday, the rest of the time I make my own decisions.” The activities records are detailed and include information on what people enjoy and what they do not. 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. A number of people said how much they had enjoyed the Pollard House DS0000056120.V357945.R01.S.doc Version 5.2 Page 13 Christmas party. There are lots of photographs of people taking part in various social activities. Some people go out alone and others with family. One person goes to the Polish club once a week. Some people said they would like the home to organise more outings, the manager is aware this is an area that needs to be developed. People told us they can visit at any time and several people commented on how friendly and welcoming the home is. One person said “Relatives are made welcome and offered a hot drink in the lounge or bedroom”. Relatives said they thought the home usually met people’s diverse needs in relation to areas such as age, culture, and religion. People’s religious needs are not always recorded and this was discussed during the visit. People said they are happy with the food; the menus have been changed to take account of people’s preferences. For example, one person has soup about an hour before lunch because staff found she was often only eating a pudding at lunchtime. Pollard House DS0000056120.V357945.R01.S.doc Version 5.2 Page 14 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 know how to make complaints and can be confident that they will be dealt with appropriately. People are protected from abuse by staff that are trained and know how to deal with any allegations. EVIDENCE: Information about how to make a complaint is readily available in the home. People living in the home and the majority of relatives said they know who to talk to if they have any concerns. People said they seldom had reason to complain but when they did their concerns were dealt with properly. One person said, “I have found that any complaints (which are few) have been dealt with effectively” Staff know what to do if people have concerns. All complaints are recorded. The majority of staff have attended training on the protection of vulnerable people (safeguarding) and know what to do if they have any concerns about the way people are being treated. The manager has demonstrated that he is aware of how to deal with situations where people’s well being is being put at Pollard House DS0000056120.V357945.R01.S.doc Version 5.2 Page 15 risk. He has not yet attended formal training on the protection of vulnerable people. Pollard House DS0000056120.V357945.R01.S.doc Version 5.2 Page 16 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. Work is continuing to improve the environment to make sure that people live in a safe and pleasant home that is suitably equipped to meet their needs. EVIDENCE: The home was clean and tidy when we visited and people said it is usually fresh and clean. The cleaning hours have been increased and the home now has domestic staff at the weekends. The new carpet cleaner has proved to be effective. There was only one room with a slight odour and the manager said the carpet in this room is to be replaced. Pollard House DS0000056120.V357945.R01.S.doc Version 5.2 Page 17 One of the ground floor toilets has been upgraded and is much cleaner and brighter. The other ground floor toilet is to be done next and after that work will start on upgrading the bathrooms. Work is continuing on improving the bedrooms, some bedrooms have been decorated and have had new soft furnishings. New furniture and soft furnishings for the remaining rooms is to be ordered. The bedroom door locks have been adjusted so that people can open them, from inside, with a single action. This reduces the risk of people being trapped in their rooms. Security to the outside is being improved. New railings have been fitted and gates with key pads are to be installed, this will give people a safe outdoor space to use. There is a designated smoking room for people living in the home; this is on the lower ground floor. The manager was advised to contact the local environmental health department to make sure this room meets requirements. The home has been awarded a four star rating (the maximum is five) by Environmental Health for the standards of food safety and hygiene. At the last visit we were concerned that all staff were not following the proper procedures to reduce the risk of cross infection, this has now been dealt with. Pollard House DS0000056120.V357945.R01.S.doc Version 5.2 Page 18 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 to meet people’s needs and people are protected because the home makes sure new staff are properly checked before they start work. Staff are encouraged to take part in training so that they have the skills and knowledge they need to care for people properly. EVIDENCE: There are usually 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. Most people said staff are available when they need them and staff take notice of what they say. One person said that at weekends they didn’t see staff in the lounges as much as they would like to, they were concerned about how people would get help if they needed it. Several people said the staff are “friendly” and “kind”. Pollard House DS0000056120.V357945.R01.S.doc Version 5.2 Page 19 NVQ (National Vocational Qualification) is ongoing, 50 of permanent staff have an NVQ level 2. Two staff have completed NVQ level 3 and 8 more staff are training working towards NVQ level 2 or 3. We looked at the files of two 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 Record Bureau) checks. New staff start their induction training in the home and complete this with an outside training company. The induction training meets the national standards and covers subjects such as confidentiality, adult protection and health and safety. These standards are designed to make sure staff get the knowledge and skills they need to care for people properly. Staff said they felt they were given a good induction and have lots of training. The training records are well organised and show what training staff have had, what training they are doing and what training is booked. Pollard House DS0000056120.V357945.R01.S.doc Version 5.2 Page 20 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People have confidence in the care home because it is led and managed appropriately. The environment is safe for people and staff because appropriate health and safety practices are carried out. EVIDENCE: Since the last inspection the manager has been registered, he is studying for the Registered Managers Award. Pollard House DS0000056120.V357945.R01.S.doc Version 5.2 Page 21 Staff told us the management team supports them, one person said, “We have regular staff meetings to cover any changes and help us understand the needs of the service users”. The records showed that staff appraisals and supervision are taking place. The home sent questionnaires to people using the service in September 2007. Ten were returned and showed that people are satisfied with the service. Several people commented on the homely atmosphere and the friendliness of the staff. The responses also showed that people have a lot of contact with the manager and appreciate this. The manager is now working on a way to summarise the results of these surveys and make the information available to people. The home used to have residents meetings but the manager found they were not really working; many people were not able to take an active part for a variety of reasons. He has replaced these meetings with one to one discussions with people. He has identified a number of subjects to include in the discussion and is keeping a record of the main points discussed. This will link in with care planning to help make sure that care is being delivered in a way that takes account of people’s wishes. The owner visits the home at least once a month and looks at all aspects of the service. We receive details reports of these visits that show us how the home is progressing and what the owners are doing to continue to improve the service. The system for dealing with people’s money has been improved. Money and records are now audited regularly to make sure that people’s money is clearly accounted for. The home’s self-assessment showed that installations and equipment are maintained and serviced at the required intervals. The home has engaged the services of an outside organisation to advise on Health & Safety and risk assessments. Pollard House DS0000056120.V357945.R01.S.doc Version 5.2 Page 22 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 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 3 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 X 3 3 3 3 Pollard House DS0000056120.V357945.R01.S.doc Version 5.2 Page 23 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. 1 Refer to Standard OP18 Good Practice Recommendations The manager should attend formal training on the protection of vulnerable people. Pollard House DS0000056120.V357945.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000056120.V357945.R01.S.doc Version 5.2 Page 25 - 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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