Inspection on 13/10/05 for Polars

This inspection was carried out on 13th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Polars 25/09/07

Polars 22/06/06

Polars 28/04/05

Polars 11/11/04

Polars 27/04/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Polars Staplers Road Newport Isle Of Wight PO30 2DE Lead Inspector Janet Ktomi Unannounced Inspection 13th October 2005 11.00 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 Polars DS0000012524.V249241.R01.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. Polars DS0000012524.V249241.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Polars Address Staplers Road Newport Isle Of Wight PO30 2DE 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) 01983 522523 01983 522546 Islecare `97 Limited Care Home 37 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (37), of places Physical disability over 65 years of age (3) Polars DS0000012524.V249241.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home currently accommodates 1 person under 65 years of age with a physical disability. No other person under the age of 65 years may be admitted. Date of last inspection Brief Description of the Service: Polars is a large detached two-storey property located in Staplers Road, Newport. Service users are all accommodated in single rooms on both floors with access to the first floor via two passenger lifts. Shared accommodation, if specifically required, could be available in the larger bedrooms. A number of rooms have en-suite facilities. Polars stands in its own extensive grounds, which are available for use by service users. There is a car park to the front of the property, from where there is level access to the home. There is a frequent bus service to Newport or Ryde with a stop located outside the home. Polars is registered to provide personal care and accommodation for up to thirty-seven (up to six with dementia and three with a physical disability) older people. The home also provides day care for older people living in the surrounding area and has a dedicated member of care staff to support these service users. The home is owned by Islecare ‘97, part of Summerset Care. The home is managed by Mr Ian Vallander who is has applied to the commission for registration. Polars DS0000012524.V249241.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second unannounced inspection of this inspection year. Core standards not assessed during the first inspection were assessed along with additional core and non-core standards. The inspection lasted five and a half hours during which a full tour of the building was undertaken. Discussions were held with service users, care staff on duty and the manager. Many of the service users living within the home were met during the inspection and gave the inspector their views about the service. All the service users stated that they enjoyed living at the home and liked the staff. Care and other records and documentation identified in the report were viewed. The inspector spoke with the Islecare ‘97 service manager by telephone following the inspection. What the service does well: What has improved since the last inspection? The home continues its programme of routine maintenance with the replacement of several of the washbasins identified as being of a particularly poor standard during the previous inspection. Service users were generally happy with the quality of food now provided at the home. Polars DS0000012524.V249241.R01.S.doc Version 5.0 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. Polars DS0000012524.V249241.R01.S.doc Version 5.0 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 Polars DS0000012524.V249241.R01.S.doc Version 5.0 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 and 4. The home fully assesses potential service users prior to admission to Polars to ensure that their needs may be fully met. EVIDENCE: The pre-admission assessments, care plans and risk assessments for people admitted to the home shortly before the inspection were viewed. These were all found to be appropriately completed with information gained during the assessment incorporated into the care plans. Specific risk assessments covering nutrition, pressure areas (Waterlow), falls and continence were included within care plans with management plans in place where required. Discussions with the manager indicated that he was clear about the purpose of pre-admission assessments and about the range of needs the home could meet and those it would not be able to accept. The manager confirmed that he undertakes assessments of people who had been admitted to hospital from the home prior to accepting them back on discharge to ensure that the home continues to be able to meet their needs. The home’s admission policy and discussions with staff confirmed that where possible people would be invited to visit the home prior to admission. Polars DS0000012524.V249241.R01.S.doc Version 5.0 Page 9 Polars DS0000012524.V249241.R01.S.doc Version 5.0 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 and 10. The home meets service users’ health, personal and social care needs whilst ensuring dignity and privacy are upheld. There is a need to improve the recording on food and fluid records. The bath water temperatures recorded in the front bathroom indicate that the water is not hot enough and places people at risk. EVIDENCE: All service users have individual care plans that contain specific information as to how individual needs and identified risks should be managed. Care plans contained specific risk assessments in respect of falls, nutrition, pressure areas (Waterlow) and continence. Care plans and risk assessments were noted to have been updated monthly and as needs/risks change. Senior staff responsible for supervising key-workers and care staff review care plans with key-workers. Many of the service users inspectors spoke with were unaware that care plans were held by the home although care plans indicated that service users or their representatives had been involved in the assessment and care planning process. It is was recommended at the previous inspection that service users or their representatives sign care plans to indicate that they have been involved in decisions as to how their care needs will be met at the home. Polars DS0000012524.V249241.R01.S.doc Version 5.0 Page 11 This had not been done in the care plans viewed by the inspector. Most of the people living at Polars are able to make decisions about their care, and confirmed verbally that choice is provided on a day to day basis, the home must demonstrate that service users are fully involved in their care plans. The home must ensure that service users or their representatives sign care plans. The home records the temperatures of the bath water prior to service users having a bath. The records for this within the front upstairs bathroom were viewed and indicated that bath water temperatures may be as low as 33º and rarely rise above 36º. This would be considered by most people to be too cold for older people to bath in and may place them at risk of ill-health. Water must be stored at a temperature of at least 60º, distributed at least at 50º to prevent the risks of legionella. Pre-set valves of a type unaffected by changes in water pressure and which have a fail safe device fitted locally should provide bath water close to 43º. The home must ensure that water is stored, distributed and provided to service users as per the above standards. The manager was required during the previous inspection to undertake random checks of the water temperature in the front part of the home, other than the bath water temperature recordings by care staff there was no evidence that this has occurred. Care staff record the food and fluid intakes for some people living at the home where there has been concern in respect of their nutritional status. The records for this were viewed and had been incompletely filled in. Should a service user become ill, this information would be required by a doctor to make a diagnosis. All records must be fully and accurately completed and the manager must ensure that care staff complete this. Service users stated that they felt the quality of personal care provided was good with choice provided as to when and how care would be provided. During a tour of the building, staff were noted to knock on service users’ bedroom doors and addressed service users in a friendly, polite manner. Service users were very positive about the care staff with interactions observed during the inspection to be warm and friendly. Discussions with care staff indicated that they treat service users as individuals. Polars DS0000012524.V249241.R01.S.doc Version 5.0 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, 14 and 15. The lifestyle experienced by service users in the home is good with opportunities for activities and choice. Service users are happy with the food provided at the home. EVIDENCE: During the unannounced inspection the inspector was able to move freely around the home, service users were observed engaged in a variety of organised and individual activities in the various communal lounges or their own bedrooms. Service users confirmed to the inspectors that they had choice over where and how they spent their time. Pre admission assessments and care plans included information about service users’ preferred times for getting up/going to bed and leisure/social activities. The home organises activities for service users including some outings to places of interest on the Island. A notice board seen within the home included photographs of a special party organised for a service user’s 100th birthday celebrations. Service users are encouraged to bring personal items including furniture to the home and the inspectors noted evidence of personalisation within all rooms. Wherever possible service users are encouraged to maintain control and management of their own financial affairs. The home does not have access to Polars DS0000012524.V249241.R01.S.doc Version 5.0 Page 13 independent advocates and, should the need arise, either a relative or care manager would be requested to fulfil this role. Discussions with service users showed that they felt able to make decisions and choices over day to day issues such as meals, times for getting up/going to bed, having personal care needs met and how and where within the home they spend their time. Care plans contain a section for service users to sign to confirm that they have been involved in the production of the care plan. Care plans viewed had not been signed by service users or their representatives. Wherever possible service users or a representative should sign the care plan. Service users spoken with during the inspection were generally happy about the food they receive at the home. Following the previous inspection service users have been involved in discussions about changes to the menu and these have been implemented. The inspector was able to see the main lunchtime meal being served and the quality and presentation appeared acceptable. Service users reported that they have a choice as to where they have meals, within their own rooms or dining room. Care staff ask service users what they would like for their main and evening meal for the following day. Service users confirmed that they have access to snacks and drinks in between meals and this was observed during the inspection. Care staff stated that special diets are catered for and healthy eating advice is provided to service users. Service users’ likes and dislikes are also taken into consideration and a note of these is made during the pre-admission assessment and recorded on care plans. Service users confirmed to the inspector that alternatives are provided when they do not like the main choice. Care staff maintain a record of any concerns re food provided. This was viewed. Ongoing random quality assurance audits by verbal or written questionnaires should be completed in respect of menus and meals. Polars DS0000012524.V249241.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Service users or their representatives are able to complain if they are unhappy with the service provided at the home. Staff are aware of adult protection issues and would respond appropriately if they had concerns in relation to adult protection. EVIDENCE: The home provides service users with information as to how to make a complaint within the service users’ information and on the hall wall. The home’s complaints policy and procedure fully complies with the requirements of the National Minimum Standards. Information as to how to complain via the Commission for Social Care Inspection is included in the service users’ information. The home maintains a record of complaints. Discussions with service users indicated that they felt able to complain and indicated that they would do so to either the manager or senior in charge. Care staff spoken with during the inspection were aware of what they should do if a service user or relative wished to complain. At the time of the unannounced inspection service users had no complaints. The home has a copy of the Isle of Wight Adult Protection Policy together with the Islecare ‘97 adult protection, gifts to staff and whistle blowing policies. A copy of the adult protection procedure was noted on the office wall. The Polars DS0000012524.V249241.R01.S.doc Version 5.0 Page 15 manager confirmed that all staff have training in respect of adult protection as part of the Islecare ‘97 induction programme. Staff spoken with during the inspection were aware of the adult protection policy and procedures and clear about their responsibilities to report issues of concern without delay. The home supports a number of service users to manage their personal allowances. The arrangements for this were viewed and a random sample audited. The arrangements and records were found to be appropriate and well maintained. The home does not become appointee for any service users. Polars DS0000012524.V249241.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 and 26. The building is in need of overall investment and improvement. The provider has long term plans for the site, however there are no firm plans in place and the safety and wellbeing of service users, visitors and staff is being compromised by the environment provided. EVIDENCE: The home is an older building that has been extended approximately forty years ago to provide the current thirty-seven single bedrooms and various communal areas. Polars is located on the main Staplers Road into Newport within walking distance of the town and with bus stops located immediately outside the home. Service users have level or ramped access to all areas within the home and garden. Two passenger lifts afford access to the first floor rooms. The proprietors, Islecare ‘97, are hoping to develop Polars to provide improved facilities and services, however there are, as yet, no firm plans in place for this to occur. The property itself is owned by the Isle of Wight Council who are responsible for external maintenance whilst the providers Islecare ‘97 are responsible for internal maintenance. Polars DS0000012524.V249241.R01.S.doc Version 5.0 Page 17 The home provides several lounges with one lounge specifically for people who wish to smoke. There is a large, pleasant dining room divided into several smaller areas. The home is surrounded by extensive gardens that are maintained by Islecare ‘97 maintenance employees and the home’s care staff. The home won prizes for the Islecare ‘97 garden competition. Patio furniture is available for service users. The radiators in the activities lounge and front lounge have not been guarded and do not have guaranteed low temperature surfaces. The home must ensure that radiators in areas accessed by service users are risk assessed and appropriately guarded. All service users are accommodated in single bedrooms, many of which have en-suite facilities and were seen during a full tour of the building. Bedrooms were seen to have been individually personalised by their occupants. Seven of the bedrooms were noted to have an unpleasant odour, some quite marked. The home has provided alternative floor coverings in some bedrooms to resolve this problem, however in some rooms this has not been successful and there is a need to further pursue the cause and options to remedy this situation. A number of the bedrooms have been redecorated and provided with new vanity units and sinks as previously required. The manager must continue this process until all the washbasins and vanity units requiring replacing have been replaced. During the tour of the building the inspector noted a number of pieces of damaged furniture that the manager is required to replace. The home undertakes a daily audit of the bedrooms, the records of which were seen during the inspection, however it was not clear how this information was then used by the manager to resolve issues identified. The audit failed to detect some of the environmental concerns raised by the inspector with the manager. In addition to those mentioned elsewhere in this report the inspector identified two bedroom windows within the front part of the home that would not close completely due to damage to the wooden window frames. These must be repaired or replaced to ensure service users’ bedrooms remain adequately warm throughout the winter. Care staff and service users confirmed that there are adequate numbers of WCs and bathrooms. During the previous inspection problems with the hot water supply to the front of the home were identified. The manager was required to ensure that hot water is available in all parts of the home. The manager was required to undertake random temperatures of the water throughout the home with the record available for inspection. This has not occurred. The only records of water temperature appeared to be that recorded by care staff of bath water temperatures prior to bathing service users. These records were seen in the front upstairs bathroom and indicated that service users were having baths in water with a recorded temperature at the start of the bath being as low as 33º. This would be considered by most people to be too cold for older people to bath in and may place them at risk of ill health. Water must be stored at a temperature of at least 60º, distributed at least at 50ºto prevent the risks of legionella. Pre-set valves of a type unaffected by changes in water pressure and which have a fail safe device fitted locally Polars DS0000012524.V249241.R01.S.doc Version 5.0 Page 18 should provide bath water close to 43º. The home must ensure that water is stored, distributed and provided to service users as per the above standards. The manager must undertake random checks of the temperature of the hot water throughout the home. The manager must ensure that the water supply does not present a risk to staff and service users from legionella. At the time of the unannounced inspection the home was found to be generally clean and tidy. The home provides hand-washing facilities for care staff with disposable gloves, aprons, soap and paper towels available in areas where they may be required. All staff receive training in infection control and food hygiene both during induction and as yearly updates. Anti-bacterial hand gel was also noted around the home. The laundry facilities were assessed during the previous inspection and found to be appropriate. Polars DS0000012524.V249241.R01.S.doc Version 5.0 Page 19 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. The home generally provides sufficient suitably experienced and qualified staff to meet the needs of service users. The records in respect of recruitment are inadequate. EVIDENCE: The inspector was shown duty rotas that indicate that four care and one senior member of staff is on duty throughout the day with two care and one sleep in senior at night. A specific member of care staff is employed for the day care service users. Sickness and holidays are generally covered by the home’s own staff with some use of agency staff. There have been a number of notifications to the commission when the home has been unable to cover staff absence from either its existing staff or agency staff. This has resulted in fewer staff than described above being available and in the senior member of staff undertaking care work in addition to managing the shift. Service users stated that care staff were kind and considerate and they felt that sufficient staff were employed in the home. In addition to care staff the home employs housekeeping and kitchen staff. The deputy manager stated that all care staff now have an NVQ of at least level 2 with the exception of staff recently appointed from overseas. Certificates for core and update training were seen within staff files. Polars DS0000012524.V249241.R01.S.doc Version 5.0 Page 20 The recruitment files for newly appointed care staff were viewed. The inspector was concerned that the application forms and information available in respect of the overseas staff was inadequate. There was no evidence of a full work history, which would enable any gaps in employment to be clarified and references taken in respect of any previous care work undertaken. Two written references were seen within the files however these were not detailed and one appeared to have been provide by a friend of the applicant. The recruitment record for a locally appointed member of staff was also viewed. This had no record or indication that a CRB or POVA check had been undertaken. The file contained a checklist for recruitment and this had only been partly completed. The staff handbooks for all the new employees were still within the staff files and there was no information available to confirm that an induction had been completed for any of these staff. The manager must review all the staff recruitment files and ensure that all information required is included and available for inspection. The manager stated that he will soon be taking more responsibility for the recruitment of staff to the home and felt that this will ensure that all the required information is in place within the staff files. Polars DS0000012524.V249241.R01.S.doc Version 5.0 Page 21 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, 37 and 39. The manager is new in post and is currently adjusting to the role and responsibilities. A number of requirements made during the previous inspection remain outstanding. The current quality assurance and record keeping procedures need to be improved. The home is generally a safe place for service users, visitors and staff although a number of safety concerns identified during the inspection and detailed in the report must be addressed. EVIDENCE: Islecare ‘97 has appointed a manager for the service who is currently undertaking the registration process with the Commission. The manager is allocated three days as management and works two days on shift. The manager has spent a number of days working in other Islecare ‘97 homes, thereby reducing the hours he has worked at Polars. The home is large and the manager must spend the allocated management hours working at Polars and not elsewhere for the company. Polars DS0000012524.V249241.R01.S.doc Version 5.0 Page 22 The deputy manager undertakes service users’ meetings for which minutes are recorded. Service users stated that they felt able to make suggestions or comments about the home. A representative of the company undertakes monthly visits to the home for which written reports are submitted to the Commission. Regulation 26 visit reports are not very detailed and in view of the number of requirements made at this inspection it is also required that the person completing the Regulation 26 visits makes a more detailed report including progress the home has made in relation to requirements. A discussion was held with the manager about ways that service users and visitors could be further involved in quality assurance. The manager is to consider options for a questionnaire that could be available for visitors near the visitors’ book and regular questionnaires that could be provided to service users. Many of the service users at the home are able to express opinions about the service and would be capable of participating in a formal quality assurance process. The home does not act as appointee for any service users. The home provides all service users with a lockable facility within their bedrooms and has a secure safe for storing money or valuables held on behalf of service users. The arrangements and records in respect of money held for individual service users were assessed and found to be appropriate and well maintained. During the unannounced inspection a variety of records was inspected. These included, care plans, care records, risk assessments, staffing rotas, Service users’ personal money, staff recruitment files, bath water temperatures, menus and dietary sheets. Service users spoken with appeared generally unaware that records were kept by the home and none expressed an interest in having access to their records. As previously stated the records of food and fluid intake were not fully completed and staff recruitment and induction records were incomplete. Care plans should, where possible, be signed by the service user or a representative. During the unannounced inspection a full tour of the building was undertaken by the inspector with the manager. A number of concerns in relation to health and safety were identified. Most have been identified elsewhere in the report. The wooden fire exit leading from the front first floor appeared slippery (a green moss had grown on the steps which were also wet due to damp weather) and must be provided with a non-slip surface. As previously stated the boiler system providing hot water to the front part of the home must be in good working order to ensure that there are no risks of legionella and that service users are provided with a suitably warm bath. The inspectors were concerned that the height of the upstairs front landing banister rail is insufficient to prevent people falling from the landing should they lean over. This should be fully risk assessed and additional height railing provided if necessary. Radiators in the activities and front lounge must be risk assessed and if appropriate, guarded or have a guaranteed low temperature surface. Polars DS0000012524.V249241.R01.S.doc Version 5.0 Page 23 Polars DS0000012524.V249241.R01.S.doc Version 5.0 Page 24 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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 3 2 X 3 2 1 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X 2 1 Polars DS0000012524.V249241.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? YES 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 OP7OP14O P37 Regulation 15 (1) 12 (2) Requirement Service users or their representatives must sign care plans to confirm that they have been involved in decisions about how care needs will be met at the home. This was required following the previous inspection. Further failure to comply with this requirement will result in enforcement action being taken. Water must be stored at a temperature of at least 60ºc and distributed at 50ºc minimum to prevent the risk of legionella. This was required following the previous inspection. Further failure to comply with this requirement will result in enforcement action being taken. Bath water must be provided at a temperature close to but not exceeding 43ºc. All records relating to care provided must be fully and accurately maintained. The company must identify to DS0000012524.V249241.R01.S.doc Timescale for action 01/11/05 2. OP8OP25O P26 12 (1) 13 (3) & (4) 14/10/05 3. 4. 5. Polars OP8OP21O P25OP26 OP8OP37 OP19 12 (1) & 13 (4) 17 (2) 17 (3) Sch 4 23 (2)(b) 14/10/05 14/10/05 01/01/06 Page 26 Version 5.0 6. OP20OP25 OP38 23 (2)(p) 7. 8. 9. OP24OP26 OP38 OP24 OP24 OP26 23 (2)(c) 23 (2)(c) 23 (2)(d) 10. OP24 OP26 23 (2)(b) 11. OP29OP37 19 (1)(b) & (c) Sch 2 12. OP30OP37 18 (1)(c(i)) 13. OP31 8 (1) 14. OP33 24 15. Polars OP33 26 (4)(b) 26 (4)(c) the commission short and long term plans for the building. Radiators in the activities and front lounge must be risk assessed and guarded or have a guarenteed low temperature surface. Damaged furniture and equipment identified to the manager must be replaced. The damaged wooden windows identified to the manager must be repaired or replaced. Action must be taken to identify the cause of and rectify the unpleasant odours noted in a number of bedrooms. The programme of replacement of vanity units and washbasins must be continued until all those requiring replacment have been attended to. All information as stated in Schedule 2 must be available in the home for all employees. Failure to comply with this requirement will result in enforcement action being taken. All staff must receive induction training, the records for which must be available for inspection. This was required following the previous inspection. Further failure to comply with this requirement will result in enforcement action being taken. The manager must not work in other Islecare ‘97 homes during hours allocated for Polars management. A formal quality assurance process must be implemented with results of surveys provided to the Commission. The report following the monthly visits by a person nominated by DS0000012524.V249241.R01.S.doc 01/01/06 01/01/06 01/12/05 01/12/05 01/01/06 01/01/06 01/12/05 15/10/05 31/03/06 01/11/05 Page 27 Version 5.0 16. OP38 23 (4)(b) 17. OP38 23 (2)(a) the provider must be more detailed and provide information as to how requirements are being achieved. The wooden fire escape identified to the manager must be made safe and provided with a non-slip surface to the treads. This was required following the previous inspection. Further failure to comply with this requirement will result in enforcement action being taken. A risk assessment must be completed on the front landing to determine if additional height to the bannister rail is required. A copy of the risk assessment must be supplied to the commisison. This was required following the previous inspection. Further failure to comply with this requirement will result in enforcement action being taken. 01/12/05 01/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Polars DS0000012524.V249241.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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 Polars DS0000012524.V249241.R01.S.doc Version 5.0 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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