Inspection on 23/11/06 for Poldhu

This inspection was carried out on 23rd November 2006.

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

Poldhu 11/12/07

Poldhu 28/11/05

Poldhu 27/07/05

Poldhu 01/02/05

Poldhu 02/09/04

Poldhu 13/05/04

Similar services:

Fairfields Country Rest Home

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

The Garden House

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

CARE HOMES FOR OLDER PEOPLE Poldhu Poldhu Cove Mullion Helston Cornwall TR12 7JG Lead Inspector Stephen Baber Key Unannounced Inspection 23rd November 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Poldhu DS0000008920.V305838.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. Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Poldhu Address Poldhu Cove Mullion Helston Cornwall TR12 7JG 01326 240977 01326 240799 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) Swallowcourt Limited Mrs T. Howard Care Home 63 Category(ies) of Old age, not falling within any other category registration, with number (63), Physical disability (20), Terminally ill (26) of places Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To accommodate one named service user only outside the normal category of the home. To accommodate one named service user with a psychiatric disorder Date of last inspection 28th November 2005 Brief Description of the Service: Poldhu has a spectacular site on the Lizard Peninsular. It is registered under the Care Standards Act 2000 and Care Homes Regulations 2001 to provide accommodation and care with nursing to a maximum of 63 people. Poldhu also offers respite care to prospective residents. Poldhu provides free transport to the service users that live in the home. Service users bedrooms are spread out throughout the home and have been completely refurbished to a high standard. There are 54 rooms in total of which 40 have ensuite facilities. 6 are double. 13 single and one double room do not have ensuite facilities but toilets and bathrooms are located near to the bedrooms. Communal accommodation is spacious and a finished to a high standard. Rooms have been personalised and reflect the individuality of the occupants. To the front of the home is a very spacious, light and airy conservatory, which has been equipped to a very high standard. The dining room is light and airy and provides a high standard of furnishings and fittings. Service users and their visitors say how comfortable and satisfied they are with the accommodation. There is a 13-person shaft lift, which travels to all three floors and aids and equipment throughout to make life easier for the more dependent service users. There is excellent enhanced doctor back-up service. The management and nursing staff are very good at networking all community and health care professionals to provide a high standard of care in very comfortable surroundings. The home employs a general manager who works closely with Mrs Howard the registered manager with C.S.C.I. The aim of the service is to provide positive outcomes for service users. Weekly fees range from £450 to £900 per week. Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission are making changes to the regulations and inspection of social care agencies. Inspecting for Better Lives (IBL). We are modernising the way we inspect all social care services and will be more proportionate, more focus on the experience of people using services and focus on providers to ensure quality. This was an annual key inspection, which took place over two days and was unannounced. It lasted for approximately 15 hours. The Commission received information about the home prior to the inspection in the form of a pre inspection questionnaire. The purpose of the inspection was to ensure that service users’ needs are appropriately met in the home, with particular regard to ensuring good outcomes for all who use the service. Throughout the two-day inspection interviews with service users and observation of the daily life and care provided were undertaken. There was an inspection of the home’s premises and of written documents concerning the care and protection of the service users and the ongoing management of the home. Staff were interviewed and observed in relation to their care practices and there was a discussion with the home’s managers. The principle method used was case tracking. This involves inspecting the care notes and documents for a select number of service users and following this through with interviews with them and/or their relatives and staff working with them. This provides a useful, in-depth insight into how service users needs are being met in the home. At this inspection, four service users were case tracked. Overall there was evidence of ongoing improvement in care standards at this inspection and work is continuing to improve it further to provide service users with a safe and comfortable home in which service users can feel comfortable and safe. This was the first inspection for Mrs Howard the registered manager. Mrs Parsons the general manager assisted her throughout the inspection and was very helpful. The inspection was a very positive inspection and I thank the managers and staff for their helpful manner to complete the inspection. What the service does well: The service provides clear written information to enable people to make a decision about whether the home can meet their needs and suit their preferences. Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 Page 6 The manager carries out detailed assessments and considers carefully if the home can meet the needs of prospective service users. There is an attention to detail in care planning and risk assessments with the manger and staff respecting individual service users lifestyle preferences and choices. Service users report that they are well cared for, they have confidence in the managers and managing director who is based at the home and does working shifts at the home. The service users said that the managers and staff are kind and skilled and respect their privacy and dignity. The managers monitor the healthcare needs of service users and ensure access to appropriate services. The managers support service users to manage their lifestyle according to the general infirmity/frailty capacity and age. Service users stated that they were very satisfied with how their healthcare needs were met and felt safe in the knowledge that the nursing and care staff were very skilled at their jobs. The management of the home is effective and ensures that the aims and objectives as set out in the statement of purpose are met. The premises are detached and set in a spectacular setting. Internally and externally the home is maintained to very high standards. Throughout the home there are aids and equipment to help daily living and systems receive regular maintenance and refurbishment, which is ongoing. The managers and staff actively consult service users individually and obtain their views about the services provided. The manager is a practitioner and works alongside the staff offering them supervision, guidance and support. The company regularly evaluate the service provided and take action to secure improvements. This was evidenced in the Quality Assurance exercise carried out this year. The company employ a training manager who works with the managers to provide a structured training programme, which covers induction, required statutory training and NVQ at levels 2 and 3. Staff stated that they are well supported and supervised. There are arrangements in place to ensure compliance with health and safety legislation and promote the health and safety of staff and service users so that they are safe and free from harm. What has improved since the last inspection? The new style of management is unique to this home. The registered manager is Mrs Howard and the general manager is Mrs Parsons. Mrs Howard is responsible for day to day nursing care of all the service users. She works in partnership with Mrs Parsons on all other matters to provided a strong management presence throughout the home, which could cover staffing issues, recruitment, service users issues, relatives matters and involvement with all community health and social care professionals. The quality of care at the home is strongly influenced by the calibre of management at the home and relationship with the company representative Mrs Allerton who has a strong Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 Page 7 presence throughout the organisation. Both ladies have the qualities and qualifications required of the person in day-to-day control of the delivery of care and how they should exercise their responsibilities. It was noted throughout the inspection that the managers were skilled at fostering an atmosphere of openness and respect in which service users, family and staff all feel valued and that their opinions matter. 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. Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5,6. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. All new service users receive a full comprehensive needs assessment before admission. For individuals who are self-funding a skilled and experienced member of staff carries out the assessment with sensitivity. The assessment covers all areas set down in the regulations. The service is highly efficient in obtaining a summary of any assessment through the care management arrangements and insists on receiving a copy of the care plan. Staff are qualified and skilled to meet the specialist needs of prospective service users. There is evidence of in-house training, which covers specialist areas of work especially for people with diverse needs. Training involves sharing current thinking and guidance and how to put it into practice. Staff are well briefed on the needs of new service users. An individual care plan is developed for each service user based on the initial assessment. It reflects the needs of the individual taking into account their cultural religious social and special needs. Admissions to Poldhu are well supported during the period of transition. Their families are also supported by contact from staff as appropriate. Terms and conditions are reviewed and kept up to date. Any changes are fully discussed with service users, their families and their representatives. EVIDENCE: Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 Page 10 Service users and their representatives receive in-depth information about the home in the form of the Statement of Purpose and Service Users guide which are well presented in a folder with the home’s brochure. The Registered Manager and the service users I spoke with said that they were given a copy of the welcome pack, which gives a lot of information about the home. Prospective service users and their relatives are welcome to visit the home and stay for a meal. The first month of their stay is a trial period. Each service user is issued with a relevant contract; in addition to the homes a copy contract is issued from the commissioning authority, Adult Social Care service. The Registered Manager visits prospective service users whenever possible to assess their needs prior to admission. She also obtains any other assessments or information from Adult Social Care services, the hospital staff, Occupational Therapists, Physiotherapists, the RATS team. The records of four recently admitted service users were case tracked. These records contained copies of terms and conditions, which comply with the standard and were signed and dated. The registered manager had carried out a range of assessments to guide, inform and direct the staff. All service users were satisfied with how their admission had been managed and one lady said she was so pleased to be in the home before winter because she had to spend so much time on her own and was lonely on her own. Poldhu does not provide Intermediate care services. Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 Page 11 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): 7,8,9,10. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staff actively promotes the service users rights of access to the health and remedial services that they need, both within the home and in the community. They have the choice and the support of staff to visit local services for medical, dental, hearing and sight checks. Regular appointments are seen as important and there are systems in place to make sure service users are reminded and appointments are not missed. Records show that the home arranges for health professionals to visit frail service users in the home and provides facilities to carryout treatment. Staff keep regular checks on health aids, making sure they are working effectively and that each service user has the necessary aids to improve their quality of life. There is evidence of current reading and learning, including training, that the home keeps up to date with professional research and literature, in both the social care and clinical fields and ensures that care plans are informed by the relevant social and clinical guidance. Quality monitoring systems include gathering the views, experiences and satisfaction service users in relation to their involvement in developing the care plan and in the review process. The home acts upon the outcomes of consultation with service users and their families. EVIDENCE: Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 Page 12 Each service user has a care plan, which was reviewed monthly. Risk assessments included a range of assessments such as Waterlow scoring, nutrition, moving and handling, falls and Barthel scoring to guide, direct and inform staff. There is a page for the GP to write notes when he visits and daily care records maintained. The documentation has been reviewed since the last inspection and was comprehensive and informative. Service users spoken with said their health needs were met and they had access to their GP or other health professionals when required. The home owned pressure relieving equipment and equipment for moving and handling. There is a suitable medicines policy and system in place for the administration of medicines. Appropriate records are maintained, storage is secure and well maintained with stock rotation in place. Only the qualified nurses manage medication. A physical check of the medication system and count of one persons medication was found to be correct. The four-service users records case tracked all had written care plans. The registered manager draws up an individual care plan for each care need, activity and risk. The plans include personal, health and social care needs. Each plan sets out a stated objective, the action to be taken and regular dated evaluations. It is recommended that service users or their representatives sign to agree their care plans. The nurses record consistent daily notes; these are factual, legible and signed. Service users were very satisfied with the care they receive. They felt that staff were courteous and respected their dignity and privacy when assisting with personal care. Staff were observed to be clearly aware of issues of sensitivity and respect for the individual in providing care. Service users see GPs in the clinical room or in their own room if they prefer. The management team are committed to a strategy for promoting equalities and diversity in all that they do in the area of age, gender, race, disability and religion. The nurse from Barbados had her work permit renewed so that she could continue to work effectively as one of the nursing team. Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 Page 13 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): 12,13,14,15., Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are able to enjoy a full and stimulating life style with a variety of options to choose from. The home has sought the views of service users and considered their varied interests and abilities when planning the routines of daily living and arranging activities. Routines are very flexible and servi9ce users can make choices in major areas of their life. The routines and plans are service user focused, regularly reviewed and can be quickly changed to meet individual service users needs. Opportunities are given to service users to share their care experiences and suggest what works well and where they would like changes to be made. Policies, procedures and practice guidance focus on service users being in control of their life. The home has appointed an activities coordinator who is responsible for creating meaningful activities and experiences both in the home and wider community. They may provide information and suggestions to help service users make their choice of activity. She meets frequently with service users to listen to their preferences. EVIDENCE: The aim of the home is to provide the service users with a qualitative experience and to empower them to have the opportunity for informed choice to maximise a fulfilled and satisfying life. I talked with the new recreational coordinator and service users about this service. Outings are arranged on an Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 Page 14 individual and group basis with the Mini bus available at all times. Whilst the recreational coordinator was able to fully explain that she takes into account a wide variation in preferences and capacity with the result that every opportunity is made to meet individual needs. Detailed records are not maintained to evidence what individual service users like to do. I observed the staff welcoming family and friends and every hospitality was given. Some family members ate with the service users. Service users can entertain visitors in their own rooms or the communal rooms. Service users said that the arrangements for visiting were good. Poldhu offers a waiting service at meal times. The first class service to the service users was noted and hot and cold drinks of all sorts were available with dinner. The service users made consistently positive comments about the quality and content of the food and the standard of catering. The menu records a varied and wholesome diet. Overall the standards are very high making for a very enjoyable dining experience. The dining room is spacious and furnished to a high standard with small tables that seat up to four and tables have clean linen tablecloths and napkins. The variety of meals was well presented and appetising, and was enjoyed by the service users. The service users were unrushed and waiting staff provided appropriate individual attention with the care assistants offering help to service users who required more assistance. Nutritional needs are assessed and special diets are catered for. Meals can be taken in the dining room; other service users prefer to eat in their own rooms. Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 Page 15 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): 16,18. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home ensures through training, supervision, review and quality monitoring that care staff fully complies with the policies and procedures provided in relation to protecting and safeguarding the rights of the service users in residence. The rights of the service users are openly discussed and understood by both service users and staff. Staff are highly motivated and committed to the consideration of rights of the individual in their work. They are willing to take considers and agreed risks to protect the rights of service users in the placement. The services principle aims and objectives include the promotion of the individual rights to live an ordinary life when ever possible and to enjoy the rights and responsibilities of citizenship. The home would involve advocates and, or volunteers to enable all service users whatever their capacity to enjoy a quality lifestyle which includes being able to attend places of religion. The service has effective arrangements in place to make sure all service users have the opportunity to vote in elections. Systems are in place to monitor the effectiveness of the promotion of rights. EVIDENCE: The complaints procedure complies with the standard. One formal complaint have been recorded and investigated in the last year. The managers actively consult service users individually and obtain their views about the services provided. The service users who spoke to the inspector were very satisfied with the service and none had felt the need to make a complaint. Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 Page 16 The home’s policy and procedure on the prevention of abuse complies in general with the standard. The reference to the Social Services Procedure needs to be amended to refer to the launched revised Local Multi-Agency Code of Practice for the Protection of Vulnerable Adults. It is recommended that the provider obtain a copy of the code of practice from the Department for Adult Social Care. I discussed the training needs of all the staff with the training manager. She state staff receives training from her in the protection of vulnerable adults during induction. The training manager has completed the multi-agency ‘alerter’s training’, which is in great demand. I spoke with some staff that were pleased with the training they receive. New systems are going to be set up regarding service users personal money. Money is going to be kept in a non interest account and can be used for personal comforts as and when service users require money. An inventory is kept of service users’ personal belongings and furniture. All records are stored securely and confidentially. Valuables are kept in the safe. Discussion took place with the new finance staff on the current operation of the computers regarding the backing up of information and storing of information off site, fire wall protection, password protection and Data Protection Act 1998. Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 Page 17 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): 19,20,21,22,23,24,25,26. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. The management and staff encourage service users to see the home as their own home. It provides a very well maintained, safe, attractive home which has all the specialist equipment and adaptations needed to meet individual service users needs. There is evidence that they meet the changing needs of all service users and especially where they have different cultural and specialist care needs. Service users tell me that they had a real choice of the room they live in and where two people share a room it was clear at their request and there are screens and or adaptations to ensure privacy. EVIDENCE: Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 Page 18 There was evidence to show that the commitment to improving the environment continues. Discussion took place with most of the service users and visiting relatives about the individual rooms and accommodation. The feedback given to me was that Poldhu provides a high standard of accommodation, décor and furnishings. A group of maintenance men have a continuous redecoration and maintenance programme which includes looking after the grounds. This is to ensure that that all parts of the home are presented and maintained to a high standard. Detailed records are maintained but this practice has now been implemented in the company homes to establish the corporate approach. Poldhu have a 13-person lift, which has access to all parts of the home. There are two lounges and entrance area where residents can relax. Bedrooms have been upgraded to provide a high standard of accommodation. I visited service users in the privacy of their rooms and they said that they enjoy their rooms, which they can personalise to their individual taste. Poldhu has a fully equipped laundry room and a laundress is employed full time to launder service users clothes. The service users commented that they were satisfied with the way their personal clothing is laundered. There are suitable bathing and toileting facilities throughout the home, which have been equipped to a high standard. Aids and adaptations were evident to assist with mobility and transfers. There were sufficient sluicing facilities in the home and protective clothing, paper towels and hand washing facilities are provided for staff. The grounds and views are spectacular and areas have been created for service users to access and to be safe weather permitting. Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 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): 27,28,29,30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users have confidence in the staff that care for them. Rotas show well thought out and creative ways of making sure that the home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the service users. Management encourage staff to undertake qualifications beyond the basic requirements and recognise the benefits of a skilled, trained workforce. The service clearly defines the roles and responsibilities of staff through accurate job descriptions and person specifications. Service users report that staff working with them are very skilled in their role and are consistently able to meet their needs. EVIDENCE: There is a recorded roster, which detail the staff’s planned work. As observed there are several nurses on duty during the morning and daytime, which means that service users can have special time set-aside for them. Care staff are in sufficient numbers to meet the needs of the service users. The training manager said that her aim for the service is to provide excellently trained staff. Poldhu exceeds the 50 level of N.V.Q level two qualifications with several staff attaining level 3. One Senior carer said he would like to undertake level 4 and the company looked favourably upon this. The following example whilst not being exhaustive is an example of some of the training provided by the company: Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 Page 20 The principles of care, moving and handling, fire prevention, food hygiene, first aid, health and safety, No Secrets, Safeguarding Adults from abuse, death dying and bereavement, infection control and role of the care worker. The home has a structured induction, which complies with the Skills For Care specification. Records of partially completed induction training were on file, with completed sections appropriately signed and dated. All staff have individual training records which include ‘Performance and Development Reviews”. There is a summary training plan, which details the training that staff have received and the ones inspected were up to date. A staff member interviewed at the time of the inspection reported that they are provided with good access and support to undertake training to develop their knowledge and skills for the benefit of service users. An area of management responsibility that has greatly improved is in the area of recruitment. There is a clear, written recruitment policy and recruitment documents provide evidence that this is adhered to in practice. There is a comprehensive policy to ensure that staff are recruited on the basis of equal opportunities. Interview records are retained and there is evidence that staff have undergone necessary checks to determine their suitability to work with vulnerable older people. . Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 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): 31,32,33,34,35,36, 37 and 38. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home has sound policies and procedures, which the manager effectively reviews and updates, inline with current thinking and practice. The manager is regarded highly by other professionals. Staff are positive in their approach to translate policy into practice. Efficient systems are in place to monitor staff adherence to policies and procedures during their practice. Management processes ensure that they receive feedback on their work. The home works to a clear health and safety policy, all staff are given a copy and regular random checks take place to ensure they are working to it. The home has a good record of meeting relevant health and safety requirements and legislation. Records are of a good standard and are routinely completed. Service users are aware of safety arrangements and have confidence in the working practices of the staff. EVIDENCE: Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 Page 22 The registered manager and general manager have managed the care home together for the past three months. Service users were very positive about the way the services and facilities are managed and commented on a number of improvements that have occurred. The home is managed in an open and transparent manner and service users are encouraged to contribute and comment upon the management and running of the service. Service users commented about the confidence they have in the management and the manner in which the home is organised to take account of their views, preferences and choices. The Responsible Individual, Mrs Allerton provides the Commission with a monthly Regulation 26 report about the services and facilities provided. A Quality Assurance questionnaire was circulated to service users and their families in August 2006. A report was compiled on completion of the surveys and a copy was made avialable to the Commission. Action plans were drawn up as a result of this exercise and management have identified the areas for improvement. Staff meetings and service users meetings are held with minutes maintained. Two new administartors have been appointed. They are currently upgrading the personal financial records of the service users. There is a policy for the safekeeping of service users money. Service users can control their own money for as long as they wish and are able to do so. Money held for service users is stored individually and securely, records are maintained and receipts are kept. Two members of staff and one manager deal with service users money and all transactions are signed for. There is going to be an upgrading of the records held in respect to service users finances. Consideration should also be given to password protection, fire wall protection and the backing up of information off site. Since taking over the managers positions more regular staff meetings and communication is taking place. The manager’s works alongside staff and regular formal 1:1 supervision with them takes place so that they have opportunities to reflect on and develop their practice. The pre-inspection questionnaire detailed required maintenance and safety checks. A sample of these were checked against the original documents and found to be accurate. There is a policy and guidance note on Legionella. Records evidence regular required checks of the fire alarm systems, emergency lighting and equipment. The company’s ‘Health and Safety Policy’ sets out the responsibilities of the employer and employees, and the arrangements for managing health and safety. There are hazard analyses and risk assessments for a range of Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 Page 23 activities and equipment. Records detail regular required checks on fire systems. The fire risk assessment has been completed but requires updating. Accidents records were appropriately completed and comply with the Data Protection Act 1998. All records inspected were up to date and in sufficient detail. Staff felt that the company paid good attention to health and safety matters. Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 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 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 4 4 3 4 4 4 4 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 4 4 3 3 3 3 3 3 Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP12 OP18 Good Practice Recommendations The registered person should encourage the involvement of service users or their representatives when agreement with the care has been reached. The registered person should maintain records of the full range of activities and outings that take place. The registered person should obtain a copy of the Local Multi-Agency Code of Practice for the Protection of Vulnerable Adults. Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Poldhu DS0000008920.V305838.R01.S.doc Version 5.2 Page 27 - 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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