Inspection on 25/09/07 for Polars

This inspection was carried out on 25th September 2007.

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

Polars 22/06/06

Polars 13/10/05

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 Mark Sims Unannounced Inspection 25th September 2007 10:30 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 Polars DS0000012524.V344891.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. Polars DS0000012524.V344891.R01.S.doc Version 5.2 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 Ltd Sarah Woodford 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.V344891.R01.S.doc Version 5.2 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. 22nd June 2006 Date of last inspection Brief Description of the Service: Polars is a large detached two-storey property located in Staplers Road, Newport. Residents are accommodated in single rooms on both floors with access to the first floor via two passenger lifts. Shared accommodation, if specifically required, could be made available in the larger bedrooms. A number of rooms have en-suite facilities. The home 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 which there is level access into 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 37 older people, with some capacity for people with dementia and for those with physical disabilities. The home also provides a day care service for older people living in the surrounding area and has a dedicated member of the care staff to support these service users. At the time of the inspection the home was under temporary management, with plans for a new permanent manager to take up the post in early July 2006. Weekly fees range from £365.40 to £432.67. The manager states that a service users’ guide is provided to all prospective residents, or their representatives where applicable. Polars DS0000012524.V344891.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a ‘Key Inspection’ of Polars Residential Home, a ‘Key Inspection’ being part of the inspection programme, which measures the service against core National Minimum Standards. The fieldwork visit, the actual visit to the site of the home, was conducted over five hours, where in addition to any paperwork that required reviewing the inspector met with service users, their relatives and staff; and undertook a tour of the premises to gauge its fitness for purpose, several issues outstanding from the last inspection were also considered during the fieldwork. The inspection process involves far more pre fieldwork visit activity, with the inspectors gathering information from a variety of professional sources, the Commission’s database, pre-inspection information provided by the service and linking with previous inspectors who have visited the home. What the service does well: Choice of Home: The service provides a good level of pre-admission information to service users and their families and makes people visiting the home, prior to arranging a permanent or temporary placement, welcome. Health and Social Care: The records maintained, indicate that people are supported to access appropriate health and social care agencies/professionals, feedback from professional sources was positive and supportive of the service provided. Daily Life and Social Contacts: The home provides a range of activities, which people can access, details of which are advertised via an internal poster and displayed upon central notice boards. Outings are also available, internal posters advertising coach trips, which occur regularly throughout the month and take in various locations and venues across the Island. Complaints and Protection: The service provides access to a complaints process, which has been drafted in accordance with the regulations and adult protection training and guidance is made available to staff. Environment: The internal environment is well presented and maintained, with all bedrooms clearly having been personalised by the occupant and all communal areas nicely decorated and furnished. Polars DS0000012524.V344891.R01.S.doc Version 5.2 Page 6 The exterior of the home has undergone some remedial works, with several replacement windows having been installed since the last inspection, however there areas of paintwork that require attention, especially around the eves and fascias. Staffing: The ratio of staff to residents is being maintained at a good level, this including both care and ancillary staff, with numerous employees seen around the home during the visit. Interactions with service users were observed to be good generally and the visitor, staff relations seemed courteous, polite and friendly. Management: The service appears to be well managed, with the manager and her deputies/assistant managers having introduced a number of systems and tools into the home for the purposes of monitoring the care delivered. As part of a large organisation the manager feels well supported in the delivery of her role and meets regularly with her line manager and managerial peers. 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 be made available in other formats on request. Polars DS0000012524.V344891.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 Polars DS0000012524.V344891.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 3 and 6: Prospective residents and their representatives have access to sufficient information when choosing the home and can expect to have their needs appropriately assessed. EVIDENCE: Admission - Assessment: The evidence indicates that people are having their needs assessed prior to admission and that they are provided with sufficient information prior to deciding to move into the home. The evidence used to make this judgement includes: o The service user comment cards indicated that people were generally happy and satisfied with information provided to them prior to making a decision about moving into the home. Polars DS0000012524.V344891.R01.S.doc Version 5.2 Page 9 o On arriving at the home the inspector noted that copies of the home’s brochure documentation was made available to people within the front entrance hallway, this literature provided a general summary of the home’s amenities and facilities and established the basic level of service people could/should expect on entering the home. A copy of the home’s revised and updated ‘Statement of Purpose’ was provided to the inspector on arrival at the home and copies of the ‘Service Users Guide’ was seen in each bedroom visited during the tour of the premises. Copies of the initial pre-admission assessment and were appropriate copies of any professional assessments undertaken, were seen on the service user plans. The assessments seen were generally informative documents, which had been completed either by the home’s manager and or a professional person, the information taken from these assessments being reflected within the care plans and supporting records. o o Standard 6: The home does not provide and intermediate care facility. Polars DS0000012524.V344891.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 7, 8, 9 and 10: The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Service User Plans: The evidence indicates that the service users are fully involved in planning and reviewing the care and support they receive. The evidence used to make this judgement includes: o Five service user plans were reviewed during the fieldwork visit, all were being regularly reviewed and updated and contained personal information relating to the client, which could only have been established with their or their relatives involvement and agreement, i.e. form of address, rising and retiring times, social histories, etc. Polars DS0000012524.V344891.R01.S.doc Version 5.2 Page 11 o The comment cards returned by the service users and their relatives indicate that people are satisfied with the care provided and that generally the service meets their needs and wishes. Observations, which established that peoples’ personal care was being delivered in a dignified and conscious manner, staff noticed knocking on doors before entering rooms (both communal and private), staff addressing people in polite and respectful terms and ensuring that ‘engaged’ notices, etc were correctly displayed when involved in delivering personal care (bathing) to clients. Staff surveys, indicate that people feel they are provided with adequate information, via the care plans, regarding the needs, wishes and abilities of the service users, these documents were noted to be readily and easily accessible to staff within the home’s main office. o o Health Care: The evidence indicates that the health care needs of the service users are being well met and monitored. The evidence used to make this judgement includes: o As indicated above a number of service user plans were reviewed during the fieldwork visit, these records found to contain not only information relating to the care and support provided in house but also details of all health and social care contacts made by or on behalf of the clients. General practitioner visits documents alongside information regarding visits undertaken by allied health care professionals: Community Nurses, Community Outreach Teams, Chiropodists, Opticians, etc. Information was also available were the client had become involved with hospital and/or clinic based appointments, including correspondence from the health service both pre and post visits. o The professional comment cards indicate that people are being and/or are consider to be being appropriately supported when accessing health care services and that their general health and wellbeing is being monitored accordingly. The latter comments / observations were supported by findings during the review of the service user plans, where health monitoring tools, waterlow, nutrition, falls, moving and handling, etc, were noticed to be in use. o Polars DS0000012524.V344891.R01.S.doc Version 5.2 Page 12 o The information taken from the service users comment cards establish that they are generally happy with the care and support provided at the home and that they are appropriately supported when accessing medical/health care services. Medication: The evidence indicates that the service users are being appropriately supported with their medications. The evidence used to make this judgement includes: o The AQAA (Annual Quality Assurance Assessment) and datasets, which make clear that policies and procedures are available to guide staff when handling service users medication. Storage facilities were seen during the inspection and considered satisfactory. Staff advised that medication training is provided and that only ‘Appointed Persons’ (assistant managers) and ‘Nominated Persons’ (seniors) can undertake medication administration. Medications are dispensed from a ‘monitored dosage system’ (MDS), which is provided by ‘Boots’, advice and guidance is available to staff if required. o o o Privacy and Respect: The evidence indicates that not all areas of home’s practice promote people’s rights to privacy and respect and that there is some room for improvement. The evidence used to make this judgement includes: o Observations made during the tour of the premise established that locks fitted to some communal facilities do not lock effectively and can be easily pushed/pulled opened. Additional observations, established that the doors to these communal facilities also do not close effectively and that the gaps that exist between the doors can be looked through. o The service users however, feel that they are treated with respect and dignity by the staff, remarks which were supported by general observations, when the carers were noted to be very respectful and courteous to both residents and their relatives, using formal and informal terms of address to engage people in conversation or provide instruction, etc. Polars DS0000012524.V344891.R01.S.doc Version 5.2 Page 13 o As indicated previously, it was observed during the tour of the premise that carers were careful to knock on closed doors before entering rooms (communal or private). It was also reported that staff were observed using engaged signs on bathroom doors to ensure people were aware when a room was in use. Polars DS0000012524.V344891.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 12, 13, 14 and 15: People who use services are able to make choices about their life style activities, whilst social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: Activities and Entertainments: The evidence indicates that the activities and entertainments provided meet the needs of the people residing at the home. The evidence used to make this judgement includes: o Internal advertisements, for weekly coach trips to various local events and destinations, were seen displayed around the home, as were details of the home’s in house entertainments programme. The inspector also observed people participating in activities during both the morning and afternoon. The first activity being a general chatted about this years Christmas festivities and the latter people creating homemade greeting cards, which are then sold internally to visitors and service users, etc. DS0000012524.V344891.R01.S.doc Version 5.2 Page 15 o Polars Both activities sessions not only involved service users but also their relatives and local volunteers, who were also observed assisting a client to complete a jigsaw puzzle. o The AQAA, makes clear that a part-time activities co-ordinator is employed at the home and that a large lounge is dedicated to the undertaking of activities/entertainments internally. In conversation with the manager, it was also established that the extensive gardens are fully accessible to service users and their relatives, as a large level pathway circumnavigates the grounds, which makes getting outside uncomplicated and easy. Records maintained by the staff and reviewed during the fieldwork visit, contain information relating to peoples social patterns / habits / preferences and document peoples enjoyment / participation in any activities arranged. Comment cards, returned by service users, further evidenced peoples satisfaction with the entertainments provided at home and that they feel there is sufficient stimulation to meet their individual needs and wishes. o o o Visiting and Family Contacts: The evidence indicates that people are able to maintain appropriate contact with their families and friends. The evidence used to make this judgement includes: o Throughout the fieldwork visit the inspector observed people entertaining visitors and involving them in the activities ongoing. Several relatives spoken with went to great lengths to express and/or impress upon the inspector their satisfaction with the service provided at Polars and their satisfaction with the homes visiting arrangements. The ‘Statement of Purpose’ and the brochure document both make reference to the homes visiting arrangement and the fact that people are welcome to undertake visits at anytime, although if the resident does not wish to see them they may be politely turned away. The home also provides a number of facilities within which a service user can entertain their visitors, including the main lounges, a quiet lounge or their bedroom. The home also provides a meeting room, which whilst small, provide a further option for people and their visitors if meeting with professional bodies or parties. Polars DS0000012524.V344891.R01.S.doc Version 5.2 Page 16 o o o Feedback from relatives, taken from the survey’s establish that people are satisfied with the efforts / arrangements made by the home / staff to ensure they and their relatives are able to keep in touch. Choice and Control: The evidence indicates that people are being appropriately supported when making independent choices and taking control of their lives. The evidence used to make this judgement includes: o The manager arranges regular service users meetings, which are fully minuted and which clearly evidence that the service users are supported and encouraged to make suggestions, etc on improvements that could be made to the service. Further evidence of the impact/success of the meetings came from the cook, who during conversation stated that the homes menu is reviewed by the service users’, during their meetings and revised according to their wishes. o Observations, which as mentioned, enabled the inspector to witness and informal meeting between the activities co-ordinator, service users and relatives, during which the arrangements for this years Christmas festivities were being discussed. The range of choices, which are presented to people on a daily basis, rising and retiring times (as documented on the care plans), meal options (determined with staff each afternoon), clothes to be worn, trips and outings to be taken, activities to be undertaken, etc. Comment cards returned by both relative’s and professional sources indicate that they feel the service promotes choice and independence for people and that people are encouraged to live according to the lifestyle they require. o o Meals and Menus: The evidence indicates that people enjoy a varied diet and are provided with a range of meals. The evidence used to make this judgement includes: o It has already been established that the service users are encouraged and supported in the process of altering and/or improving the menu options via their service user meetings. Copies of the homes three weekly rotational menus were provided to the inspector as part of the inspection process, the menus indicating that the o Polars DS0000012524.V344891.R01.S.doc Version 5.2 Page 17 diet provided at the home is both wholesome and nutritious and that choice is provided daily with two main meal options offered. o In conversation with the cooks, it was established that generally they prefer to cater for the needs of the service users and that should somebody not like either menu option or prefer to eat something different this is not a problem. On the day of the fieldwork visit the cooks were able to demonstrate this, via the record of the food served and/or chosen by the clients, one person requesting sausage’s, which were not on the menu but which the cooks provided. o The feedback from the service user comment cards also indicates that as a group the service users are happy and satisfied with the meals provided. Polars DS0000012524.V344891.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 16 and 18: People who use the service are able to express their concerns and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. EVIDENCE: Complaints: The evidence indicates that people are both aware of their rights to make complaints and happy to raise issues with the management. The evidence used to make this judgement includes: o The dataset, which contains details of the home’s complaints activity over the last twelve months: 1. 2. 3. 4. 5. o No of complaints: 2. No of complaints substantiated: 1. No of complaints partially substantiated: 1. Percentage of complaints responded to within 28 days: 100 . No of complaints pending an outcome: 0. During the fieldwork visit the manager was able to produce the homes complaints logs, which indicated that since the dataset had been completed a third complaint had been received by the home and that this DS0000012524.V344891.R01.S.doc Version 5.2 Page 19 Polars had been investigated and an outcome letter provided to the complaint within the required timescale. o o The dataset also establishes the existence of the home’s complaints and concerns procedure, which was last updated in January 2007. The service users and their relatives comment cards all indicate that people are both aware of and confident in the use of the homes complaints process, all ticked: ‘Yes’ in response to the question ‘do you know how to make a complaint’. Protection: The evidence indicates that people are appropriately protected from abuse and/or harm. The evidence used to make this judgement includes: o The dataset establishes that staff have access to policies and procedures on the safeguarding of vulnerable adults: 1. Safeguarding adults and the prevention of abuse last reviewed and updated in January 2007. 2. Disclosure of abuse and bad practice last updated and reviewed in January 2007. o The manager, via the AQAA, states that all staff, during their induction receive training on or around ‘safeguarding’ people and records are in place to evidence that this training has been completed, although the induction does not comply with ‘Skills For Care’ (SFC) guidance. The dataset also indicates that there have been no Adult Protection Investigations or safeguarding referrals, a statement supported during a review of the Commission’s databases, which indicate that no referrals have been made under the above policies or procedures and copied to the Commission. The indication from service users, their relatives and professionals is that they are satisfied with the overall care provided at the home. o o Polars DS0000012524.V344891.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 19 and 26: The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: Environment: The evidence indicates that the environment is well maintained and meeting the needs of the service users. The evidence used to make this judgement includes: o A tour of the premise, which enabled the inspector to ascertain that the property, internally, is in a good state of repair, several bedrooms and the corridors having recently been redecorated. Polars DS0000012524.V344891.R01.S.doc Version 5.2 Page 21 Externally some attention have been given to the building, several windows having been replaced, however, the decorative condition of the facia and the eve’s, especially to the rear of the property are poor and they will require attention in the near future to prevent rotting and improve their cosmetic appearance. o The AQAA also indicates that new furniture has been purchased with the intention of creating a more comfortable and homely environment for the service users. Observations and discussions with service users established that the environment is in deed considered to be comfortable, however, it size and layout does impede the creation of a truly homely atmosphere, although the manager and her staff have done well in establishing the individual lounges each with a differing ambiance and use, television lounge, quiet lounge, activities lounge, dining room and visitors room. In conversation with the manager it was evident that she has no problems in getting work carried out on the premise if required and that the management at Islecare have been very supportive. However, she did point out that their remit extents only to internal aspects of the property and that externally the maintenance of the home is the Councils responsibility as the Landlord, who are sometimes a little slow to address issues. Cleanliness and Hygiene: The evidence indicates that the home is generally clean and tidy. The evidence used to make this judgement includes: o A tour of the premise was undertaken, when in addition to considering the decorative condition of the home the inspector also monitored the cleanliness of the property, which was good. In conversation with the manager, it was established that at a recent team meeting, it was decided that the domestic staff would take on some additional tasks/roles performed by the care staff, which the staff felt would improve the general cleanliness of the home and ensure clarity existed between the jobs and people responsibilities. Several relative comment cards had indicated that the cleanliness of the home and occasional problems with bedrooms not being cleaned properly was the home’s big area for improvement. Given the recent changes agreed by the staff and manager, as highlighted above, it is hoped/envisaged that the problems encountered should become less frequent. DS0000012524.V344891.R01.S.doc Version 5.2 Page 22 o o o o Polars o From the perspective of the service users it is clear that they find and/or consider the home to be clean, tidy and fresh throughout and raised no concerns via the comment cards returned. The dataset establishes that staff have access to both infection control and health and safety guidance and that these documents reviewed and updated in the January 2007. Staff training records indicate that annually the staff attend mandatory training programmes, which revisit both infection control and health and safety issues as part of a skills/development programme. o o Polars DS0000012524.V344891.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 27, 28, 29 and 30: Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: Staffing Resources: The evidence indicates that sufficient staff are employed to meet the needs of the service users. The evidence used to make this judgement includes: o Information taken from the AQAA where the manager states she produces four weekly staff roster, which are displayed within the office at all times. This statement was confirmed during the fieldwork visit when the inspector checked the rosters, determining that staff are deployed as follows: AM. Four carers and a senior 07:30 hrs to 08:00 hrs AM. Five Carers and a senior 08:00 hrs to 14:00 hrs PM. Four carers and a senior 14:00 hrs to 22:00 hrs Night. Two carers 21:00 hrs to 07:30 hrs, both are waking care staff. Polars DS0000012524.V344891.R01.S.doc Version 5.2 Page 24 o Night. One senior on call on the premise between 22:00 hrs and 07:00hrs. In addition to the care staff the home also employs: Two catering staff from 07:30 hrs to 13:30 hrs dropping to one cook until 16:00 hrs Two domestic staff one from 08:00 hrs to 14:30 hrs and the second from 09:00 hrs to 13:00 hrs across a five-day week One administrator from 09:00 hrs to 12:30 hrs One activities co-ordinator from 08:00 hrs to 16:00 hrs The manager works supernumerary across a five-day week. o One relative comment card raised concerns that the staffing levels may not be adequate to meet the needs of the service users, indicating that at weekends for example it can sometimes take longer for staff to answer call bells. However, the remaining three relative comment cards and the eleven service user comment cards do not identify any concerns and praise the staff for the care and attention provided to both residents and their visitors. o Observations, made during the fieldwork visit, would also appear to support the view that sufficient staff are employed at the home. Staff seen to be involved in the afternoons activities, call bells responded too without undue delay, staff involved in a variety of tasks laundry, drinks rounds, etc. Training & Development: The evidence indicates that the training opportunities for the staff are reasonable. The evidence used to make this judgement includes: o Feedback from the staff surveys indicates that training opportunities are considered to be good and relevant to the person’s role. These findings mirror those of the company’s annual staff survey, which received 14 responses and has been broken down into a bar chart presentation for the manager. All fourteen respondents felt they had a clear understanding of their role and ten of the fourteen felt they had been given ample opportunity to learn and grow within the work place. o The manager, during the fieldwork visit, was able to produce copies of the training matrix/records that she maintains in order to track the DS0000012524.V344891.R01.S.doc Version 5.2 Page 25 Polars staffs training achievements throughout the year and to monitor when the staff need to attend training updates, etc. The manager also maintains copies of the certificates awarded, following the successful completion of a course or training event, these are kept within the staff members employment file for reference purposes. o The relative comment cards indicate that people are generally satisfied with the service provided at Polars and that they feel the staff have both skills and experience required for the roles they perform. Professional feedback also indicates that they are also satisfied with the skills and experience of the staff and manager. The manager has via the AQAA indicated that the home has an induction programme in place. This is a company induction and whist it provides a good introduction to the work place and the company as an employer, it does not address the fundamentals of care, as reflect through the SFC induction, which the staff should be completing. Information taken from the dataset and confirmed during the visit, indicates` that currently the home employs 30 care staff. 15 of 30 care staff have completed a National Vocational Qualification (NVQ) at level 2 or above, giving the home a percentage of 50 of its care staff possessing an NVQ at level 2 or above. The dataset also indicates that 8 care staff are presently completing an NVQ level 2 or above, which should the carers pass the course, could raise the home’s percentage rate to 77 . Recruitment and Selection: The evidence indicates that the recruitment and selection process is being appropriately operated. The evidence used to make this judgement includes: o At this visit the files of the last two people to be employed at the home were reviewed and found to contain the following information: 1. 2. 3. 4. 5. 6. 7. 8. Polars o o o Application forms Two written references Dates of employment Protection Of Vulnerable Adults (POVA) clearance Criminal Records Bureau (CRB) check outcome Induction details (in house) Photo Identification Contract DS0000012524.V344891.R01.S.doc Version 5.2 Page 26 9. Supporting Documentation (CRB & POVA) 10.Interview records. o The dataset establishes that a recruitment and selection strategy/procedure exists to support the manager when employing new staff. The manager during conversation indicated that the majority of the clerical work, around recruitment, etc, is undertaken at Islecare’s central office and that she is involved in short listing and interviewing prospective candidates. Each file does include/incorporate a checklist, which is completed by the administration team at Islecare’s central office, which tracks the date information is request i.e. references and the date returned. o The staff surveys also indicate that prior to being employed at Polars, they were asked to submit to reference, CRB and POVA checks. o Polars DS0000012524.V344891.R01.S.doc Version 5.2 Page 27 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 31, 33, 35 and 38: The management and administration of the home is based on openness and respect, and has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: Management: The evidence indicates that the home is currently being managed to a high standard. The evidence used to make this judgement includes: o The information already contained within this report supports the fact that this service is being well run and is operating in the best interest of the service users. DS0000012524.V344891.R01.S.doc Version 5.2 Page 28 Polars o Observations of the systems in place to help ensure the smooth running of the home: 1. 2. 3. 4. 5. 6. 7. 8. Recruitment and Selection process Training Matrix/records and Plan Service User Plans Quality Audits Complaints / Comment System Service User/Staff meetings Arrangements for Activities Maintenance of the Premise o The AQAA makes clear that the manager has ten years worth of experience of running and managing services within the social care sector and that she possesses an NVQ level 4 in care, has completed the Social Services Management Award and is presently completing the Registered Managers Award. The staff surveys also indicate that the staff feel well supported by the management of the home, that they are being provided with opportunities to discuss their personal development and that they receive regular supervision sessions. o Quality Audit and Assurance: The evidence indicates that service users and/or their relatives are afforded the opportunity to comment on the service provided at the home. The evidence used to make this judgement includes: o During the tour of the premise it was noticed that flyers were on display advertising the forthcoming residents meetings, the flyer listing the years dates from 26th January to 17th December 2007 for all meetings. The manager also retains copies of both the agenda’s and minutes of the meetings, which consider various aspects of the service, as shown by the catering staff who confirmed that the menu’s have been discussed at these meetings. o On arriving at the home the inspector noticed that satisfaction surveys are being made available to both service users and their visitors, within the front entrance hallway. In discussion with the manager it was explained that these surveys are sent to Islecare’s parent company, ‘Somerset Care’ and that the information is used as part of the company’s wider client satisfaction audits. Polars DS0000012524.V344891.R01.S.doc Version 5.2 Page 29 o The manager also discussed and demonstrated the company’s internal audit, which require the manager’s to rate their service against the ‘National Minimum Standards’ (NMS) and to indicate where and how they can evidence compliance with the standards. This is apparently and ongoing process, with the manager’s requested to complete a different outcome area each month and forward the completed assessment to the company for consideration. Representatives of the parent company also undertake auditing visits to the home as part of this process, whilst representatives of the Islecare management team carry out ‘Regulation 26’ visits, which are required by law. o Senior staff meetings also occur on a regular basis and are also minuted by the manager for reference purposes and to monitor progress on agenda items, etc. As with the resident meetings, flyers/advertises are on display around the home indicating to staff when the next meeting is planned for, this has also been scheduled a year in advance. o In addition to the monthly care plan reviews, which take place the manager has introduced six monthly client reviews, which are intended to consider all aspects of a person’s needs, wishes and requirements of the service. This has been introduced by the manager and is a process carried out / provided for privately funded clients, as those clients funded by the Local Authority receive six monthly care manager reviews, which consider the same issues. Records of these reviews are maintained on the client’s files and people significant in the care and support of that person are invited to attend the reviews. Service users finances: The evidence indicates that the arrangements within the home promote independent when managing finances. The evidence used to make this judgement includes: o The tour of the premise established that each person is provided with and/or room fitted with a security box/safe within which to keep valuable items and their finances. Polars DS0000012524.V344891.R01.S.doc Version 5.2 Page 30 The manager explained that each client is provided with a key to this facility and that a master key is available if required, although this is safely and securely maintained. o The AQAA makes a clear statement that where the home is involved in supporting people with their personal monies, etc, that records are maintained to account for all incomings and outgoings, including receipts for purchases, etc. The monies are held in a safe storage facility and access to this is restricted to the home’s administrator, senior staff and the manager. No concerns have been raised with the Commission either in the build up to the inspection and fieldwork visit or as part of the inspection process. o o Health and Safety: The evidence indicates that the health and safety of the service users and staff is not being reasonably managed. o o The tour of the premise raised no immediate concerns with regards to the health and safety risks possessed by the building. The manager and/or company representatives have identified environmental risks and risk assessments are in place, as is appropriate signage and warning symbols/alerts, where applicable. The AQAA and dataset information establishes that full health and safety policies/guidance documents are made available to the staff and that equipment is regularly maintained and serviced, gas, electrical installations, portable electrical appliances, hoists, baths, etc. Health and safety training is clearly made available to staff, with the staffing records indicating that mandatory training events, which address issues such as: moving and handling, infection control, fire safety, etc are being delivered. o o Polars DS0000012524.V344891.R01.S.doc Version 5.2 Page 31 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 3 8 3 9 3 10 2 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 X X X X X 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 X 3 X 3 X X 3 Polars DS0000012524.V344891.R01.S.doc Version 5.2 Page 32 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. 1. Standard OP10 Regulation Requirement Timescale for action 03/11/07 Regulation The manager must make 23 arrangement for suitable locks to be fitted to the doors of the communal facilities, which are split doors. The manager must also make arrangements for the gaps between the split doors to be obscured/filled to prevent people being able to see into the facility. 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.V344891.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Polars DS0000012524.V344891.R01.S.doc Version 5.2 Page 34 - 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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