Inspection on 28/04/05 for Polars

This inspection was carried out on 28th April 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Polars 25/09/07

Polars 22/06/06

Polars 13/10/05

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 28h April 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Polars Version 1.10 Page 3 SERVICE INFORMATION Name of service Polars Address Staplers Road, Newport, Isle of Wight, PO30 2DE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01983 522523 01983 522546 Islecare 97 Ltd Mrs Amanda Minshull 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 Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 11/11/2004 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 37 (up to 6 with Dementia and 3 with 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. At the time of the unannounced inspection the home is without a registered manager and the company, Islecare 97, is actively trying to recruit a suitable manager. Polars Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the first unannounced inspection of this inspection year, core and additional standards were assessed. Core standards not assessed during this inspection will be assessed during the second unannounced inspection. The inspection, which was undertaken by two inspectors, lasted six and a three quarter hours during which a full tour of the building was undertaken. Discussions were held with a number of residents, visitors, the acting manager and staff on duty. Records and documentation identified in the report were viewed. What the service does well: What has improved since the last inspection? The home has continued its programme of routine maintenance and has completed all the environmental requirements made following the previous inspection. The home is now fully staffed and uses few bank or agency staff. Polars Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Polars Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Polars Version 1.10 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 standard(s) 1, 3, 4 and 5 The home fully assesses potential service users prior to admission to Polars to ensure that their needs may be fully met. The service users’ guide provides information to service users and their representatives to enable them to be aware of the facilities and services the home provides. Standard 6 has not been assessed as intermediate care is not provided at the home. EVIDENCE: A copy of the statement of purpose and service users’ guide was available in the front hall alongside the visitors’ signing in/out book. This contained all the required information in a typed format that would be appropriate for most service users and their representatives. The acting manager stated that copies of the service users’ guide were provide to service users when they were admitted to the home. The pre-admission assessments, care plans and risk assessments for the three people admitted to the home in April 2005 were viewed during the inspection. 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 Polars Version 1.10 Page 9 management plans in place where required. Discussions with the acting manager and acting deputy manger indicated that they were 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 home’s admission policy and discussions with staff confirmed that where possible people would be invited to visit the home prior to admission. A number of recent admissions to the home had previously attended day services at the home prior to admission for residential care. Some service users are admitted directly from hospital and visits are not possible to arrange. The acting manager confirmed that in such circumstances representatives of the person to be admitted were invited to visit the home and senior staff met with the person in hospital whilst undertaking the pre-admission assessment. The home would aim to avoid emergency admissions unless the person was already known to the home such as via attendance at the day service or previously for short term care. Polars Version 1.10 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 standard(s) 7, 8, 9 and10. The home meets service users’ health, personal and social care needs whilst ensuring dignity and privacy are upheld. Medication is appropriately stored and administered by the home’s senior care staff. EVIDENCE: All service users have individual care plans that contain specific information as to how individual needs and identified risks should be managed. The inspectors viewed six service users’ assessments and care plans selected at random. 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 recommended 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 Version 1.10 Page 11 The acting manager stated that the home aims to meet all the health needs of service users and works closely with external professionals such as GPs and District Nurses. All service users are registered with GPs in the Newport area. Service users are able to remain registered with their own GP as long as Polars is within the GP’s geographical area. Information within care plans identifies existing health needs and details the level of care and support individual service users require to ensure health needs are met. Care plans also contain information about dental, optician and chiropody arrangements. All service users have pressure area (Waterlow) assessments recorded in care plans and updated as required. The home has equipment necessary for the promotion of tissue viability and seeks the advice of district nurses if required. Staff have received training to support service users’ psychological needs and care for those with dementia. Care plans were also seen to contain nutritional assessments and service users’ weight is recorded when necessary. Service users spoken with during the inspection confirmed that all personal care is provided in private, with all service users being accommodated in single bedrooms. 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. Staff stated, and service users confirmed, that all medical examinations and treatment take place either in the service user’s bedroom or in the district nurse’s room. The deputy manager confirmed that all care staff receive training in relation to dignity, confidentiality and privacy during their induction period and this is recorded within their staff handbook. Medication, which is dispensed via a pre-packed monitored dosage system, is always administered by a senior member of staff who has been deemed competent to do so. Any unused medication is returned to the pharmacy for disposal and a record kept of these, countersigned by the pharmacy. Medication was found to be stored in an appropriate locked facility. Records are kept in regard to all medications received into the home and administered by staff. At the time of the inspection no controlled medications were in use within the home however the home has an appropriate storage facility, policy and procedure should controlled medication be prescribed to a service user. The home has a fridge located within the locked district nurse’s room where medications that need to be kept cool may be stored. Service users who have been assessed as able to self-administer their medication are able to do so. All senior staff who administer medications have undertaken the BTEC Medications Award. Polars Version 1.10 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 standard(s) 12, 13, 14 and 15. The lifestyle experienced by service users in the home is good with the exception of the quality of meals provided which falls below the standard expected by service users and the National Minimum Standards expected by the inspectors. EVIDENCE: During the unannounced inspection the two inspectors were 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 events and information about activities. During the unannounced inspection there were a number of visitors to the home. Visitors confirmed that they are made welcome and able to visit their relative or friend in private if they wish. A small meeting room is available on Polars Version 1.10 Page 13 the first floor, accessible by shaft lift, should the service user’s bedroom not be appropriate for a private visit or meeting. 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 independent advocates, the manager stated that 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. Minutes of the most recent service users’ meeting were seen during the inspection with service users confirming that they are encouraged to attend and contribute at service users’ meetings. Service users spoken with during the inspection were generally unhappy about the food they receive at the home, stating that food quality varied depending on which chef was on duty and that although some choice was available the menus were repetitive. The inspectors were able to see the main lunchtime meal being served and felt that this was unappetising. Service users reported that they have a choice as to where they have meals, within their own rooms or dining room. The home employs two chefs who prepare all meals. Fourweekly menus were seen and changes to the menu are discussed at the service user meetings. Care staff ask service users what they would like for their main and evening meal for the following day. Care staff were seen providing alternative food for a service user who was unwell at the time of the unannounced inspection and had been asleep when the lunchtime meal was served. The minutes of the service users’ meeting showed that service users are encouraged to make comments on and suggestions for changes to the menus. Service users confirmed that they have access to snacks and drinks in between meals and this was observed during the inspection. The manager and cook 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. The home is required to review the menus and catering arrangements to ensure that service users are provided with appetising well-cooked nutritious meals. The manager must undertake random audits (by verbal or written questionnaires) to cover breakfast, lunch and evening meals. The results of the random audits must be used to improve the food provided to service users and be available for inspection. Polars Version 1.10 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 standard(s) 17 and 18 The home protects service users from abuse and ensures that their legal rights are protected. EVIDENCE: 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 manager confirmed that all staff have training in respect of adult protection as part of the Islecare 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 will be assessed during the next unannounced inspection. The home’s employment procedures should ensure that unsuitable people do not work within the home. The acting manager stated that all service users are registered on the electoral roll and that polling cards or postal votes for the forthcoming election had been received and given to service users. The manager reported that she had had limited success with obtaining advocates in the past and referred advocacy issues to care managers. Polars Version 1.10 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 23, 24, 25 and 26. The home provides good quality private (bedrooms) and communal (lounges and dining rooms) accommodation for service users. However the building is in need of overall investment and improvement that is unlikely to be achievable whilst the current owners of the building (Isle of Wight Council) and the service providers Islecare ‘97 are unable to agree on a long term proposal for developing the service. The safety and welfare of service users and staff is compromised by staff having to carry hot water from the ground floor to upper floors. 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, is hoping to develop Polars to provide Polars Version 1.10 Page 16 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, is responsible for internal maintenance. The acting manager confirmed that there is a programme of ongoing decoration by maintenance staff employed by Islecare ‘97 and the home was found to be in a good state of internal decoration. 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 employees. The lawns had recently been cut and staff confirmed that service users are able to enjoy the gardens in warmer weather. Patio furniture is available for service users although staff stated that they will take more comfortable chairs outside for people to sit on. 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 and lounges were appropriately furnished with bedrooms being individually personalised by their occupants. Care staff and service users confirmed that there are adequate numbers of WCs and bathrooms. However it was apparent during the inspection that there have been problems with the hot water supply to the front part of the building with external professionals (plumbers and heating engineers) being requested to visit on approximately twelve occasions over the past year. The deputy manager confirmed that this has been a problem, and that the front upstairs bathroom is often not used by service users who use bathrooms to the rear of the building as the water supply is not hot enough to bath in. Care staff confirmed that on occasions hot water has been carried from the ground floor still room to enable service users upstairs to have water hot enough to wash with. This represents health and safety risks to staff and service users. The home must ensure that the problems with the existing hot water supply are permanently resolved and provide a continuous supply of appropriately hot water to all areas of the home. At the time of the unannounced inspection the home was found to be generally clean and tidy, however one visitor did inform the inspectors that she had had to request that her mother’s bedroom was cleaned on two occasions. The home employs two part time housekeepers. Duty rotas seen indicate that when one housekeeper is on holiday or sick leave that there are several days during the week when there is no domestic support to care staff. The housekeepers also undertake laundry duties. In the absence of the housekeepers these tasks are undertaken by care staff, removing them from caring duties for a period of time. 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. Antibacterial hand gel was also noted around the home. Polars Version 1.10 Page 17 Polars Version 1.10 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30. The home employs sufficient care staff to meet service users’ needs and ensures that care staff are appropriately trained and competent to do their jobs. EVIDENCE: All newly appointed staff receive a staff handbook and comprehensive induction programme that includes regular supervision with a nominated member of the senior care team. The inspectors were shown a copy of the staff handbook and recommend that senior staff photocopy the section in the handbook where care staff and supervisor sign to confirm that all areas of their induction have been covered before care staff take the handbook home. This will enable the home to demonstrate that all staff have received an appropriate induction covering all the necessary topics, policies and procedures. Uncovered shifts, resulting from vacancies, holidays or sickness are usually covered by the home’s existing care staff. On occasions it is necessary to use bank or agency staff and the home has an induction checklist specifically for this purpose. This is signed by the senior on duty and the agency/bank worker and held within the home. All staff complete statutory basic and update training in fire awareness, infection control, food hygiene, moving and handling and health and safety. Additional training is provided to ensure that the needs of service users can be met. The acting manager informed the inspectors that the home is virtually fully staffed with appropriate numbers of care and senior staff. The home provides one senior on duty at all times (at night the senior does a sleep-in shift), and Polars Version 1.10 Page 19 at least four care staff. In addition, the manager or deputy manager undertakes a daytime shift to ensure that all administration/management tasks can be covered and allow the senior carer to support care staff. Separate care staff are provided for the day service attendees and to provide activities for service users. At night two care staff are on duty with a senior available on call within the home. Service users, visitors and care staff felt that there were appropriate numbers of staff employed at the home, although short notice sickness could result in shifts being one care staff short. The home notifies the Commission of such incidents and such notifications have reduced in the weeks prior to the unannounced inspection. In addition to care staff the home employs catering and domestic staff. As stated within the environment section of this report there may be a need to review the arrangements for the domestic staff to ensure that all areas of the home are cleaned when either of the part time domestics is on leave. Service users were happy with the care staff working in the home who they felt treated them with dignity and respect and allowed them to make choices as to when and how care would be provided e.g. whether they wanted to have a bath or assistance with a wash to maintain personal hygiene. Polars Version 1.10 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 34, 36, 37 and 38. The home needs to appoint a permanent registered manager and ensure a clear management structure to ensure that the existing good care to service users continues. All staff are well supervised and trained. Staff have training in health and safety, food hygiene, infection control and manual handling. The home is generally a safe place for service users, visitors and staff although a number of health and safety concerns identified during the inspection and detailed in the report must be addressed. EVIDENCE: At the time of the unannounced inspection the home was without a registered manager, the registered manager having moved to an alternative management position within the same company four months prior to the inspection. The company, Islecare ’97, has sought to appoint a new manager and had held interviews the week prior to the inspection. At the time of the inspection an appointment had not been confirmed and senior staff within the home who had Polars Version 1.10 Page 21 been acting up as manager, deputy manager and assistant manager were unsure of their future roles. It is important that a home of this size has a manager. Should a manager not be appointed on this occasion then the company should discuss with the Commission the management arrangements for the home until a manager is appointed. The acting manager confirmed to the inspectors that the home has a very high occupancy level with one vacancy at the time of the unannounced inspection. The home would appear to be financially viable with appropriate insurance certificates seen during the inspection. Employment policies and procedures adopted by the home include formal supervision at least six times per year with an annual appraisal. Senior and care staff confirmed that supervisions occur with a list of which senior staff supervise care staff being seen on the office wall. At the start of the inspection the acting manager was supervising a senior member of care staff. The home has regular staff meetings, the minutes of which were seen during the inspection. Ancillary staff also receive supervision and additional supervision is provided for newly appointed staff. During the unannounced inspection a variety of records was inspected. These included fire equipment safety check log, care plans, risk assessments, staffing rotas, accident and incident books, Medication Administration Records, maintenance requests, menus and dietary sheets. All were found to be well maintained and appropriately stored. 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. During the unannounced inspection a full tour of the building was undertaken by the inspectors. A number of concerns in relation to health and safety were identified. An electric extension lead was noted in the dining room that appeared to have been repaired using red tape. This must be replaced immediately. 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 rain) 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 so that staff are not carrying hot water to service users’ rooms. 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. Polars Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 3 2 x 3 3 2 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x 3 3 2 x x 3 x 3 3 2 Polars Version 1.10 Page 23 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 15 Regulation 16(2)(1) Requirement The home must provide nutritious appetising food. The home must undertake random audits of food provided and use the information obtained to alter menus and catering arrangements. The home must ensure that hot water is available in all parts of the home. The manager must randomly record temperatures of hot water throughout the home and the record must be available for inspection. The management arrangements within the home must be finalised and the Commission informed of the arrangements. The electric extension lead in the dining room must be replaced. The wooden fire exit identified to the acting deputy manager must be made safe and ensure not slippery during wet weather. The proprieters should complete a thorough risk assessment of the upstairs landing to determine if additional height to the bannister is required. Timescale for action immediate 1-5-05 2. 21, 25, 38 23(2)(b) 23(2)(j) 31-5-05 3. 31 8(1)(a) 31-5-05 4. 5. 38 38 23(2)(c) 23(4)(b) immediatel 28-4-05 15-5-05 6. 38 21 31-5-05 Polars Version 1.10 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 7 30 Good Practice Recommendations Service users or their representatives should sign care plans to confirm that they have been involved in decisions about how care needs will be met at the home. The manager should ensure that the relevant page within the staff handbook is photcopied by senior staff as evidence that a full induction has been provided to all care staff. Polars Version 1.10 Page 25 Commission for Social Care Inspection Mill Court Furrlongs Newport 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 Version 1.10 Page 26 - 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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