Inspection on 28/11/05 for Poldhu

This inspection was carried out on 28th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Poldhu 11/12/07

Poldhu 23/11/06

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 Announced Inspection 28th November 2005 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.V252621.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Poldhu DS0000008920.V252621.R01.S.doc Version 5.0 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 Thomas Richard Cousins 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.V252621.R01.S.doc Version 5.0 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 27th July 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 residents that live in the home. Residents 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 and residents said how comfortable and satisfied they are with the accommodation.There is a new 13 person shaft lift which travels to all three floors and aids and equipment throughout to make life easier for the more dependent residents. There is excellent enhanced doctor back-up with weekly surgeries held at the home and the nursing and care staff are very good at networking all community and health care professionals to provide a high standard of care in very comfortable surroundings. Poldhu DS0000008920.V252621.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the announced inspection as part of the homes annual inspection programme. The inspection took place over two weekdays on the 28th and 29th November 2005 and 16 hours was spent over the two days inspecting records and the premises, talking with residents, relatives and staff. A new manager designate has been appointed and commenced employment in August 2005. The manager was present throughout the two-day inspection. The following activities were also carried out: • Inspection of policies and procedures, records, including assessment information and care plans • Discussion with the acting manager of the home on how it operates on a day-to-day basis • Inspection of the building • Observation of the daily life of the home . The inspection report shows that the manager has reviewed all aspects of recording and staff development. I spent time talking with residents who said that they were very comfortable and well cared for. The relatives confirmed that they were always made to feel comfortable and were impressed with the hospitality afforded them. I noticed that relatives were taking lunch with their relatives with no cost to them incurred. Relatives said that they were kept fully informed about matters and staff were efficient and professional about their business. The statement of purpose and service users guide set out the homes objectives in relation to privacy and dignity. Records in the home were well maintained, up to date and professional in their content. Throughout the two day inspection open and frank discussion took place with the manager designate who explained his vision for the home which was supported by the managing director who offers support on a daily basis which the manager is appreciative of. What the service does well: The management team have introduced improved opportunities to meet and make changes. More regular staff and resident meetings take place and the residents are encouraged to set their agenda. The service provides clear Poldhu DS0000008920.V252621.R01.S.doc Version 5.0 Page 6 written information to enable people to make a decision about whether the home can meet their needs and suit their preferences of the residents. The home provides a high standard of accommodation and is comfortable, well maintained and homely, which meets the needs of the residents. The premises are very clean and hygienic with equipment and protective clothing purchased for staff to make their jobs easier. The manager and nursing team carry out detailed assessment of needs before the home makes a decision about whether they can meet the needs of prospective residents. There is attention to detail in care planning and risk assessment with information now being shared with residents and their representatives. Residents said that they are well cared for and were comfortable and that they have confidence in the management team who they said are very skilled in their job. The home receives an enhanced doctor service with a weekly surgery being held in the home. The residents stated that they receive a first class health care service and the staff were responsive to their needs and respects their privacy and dignity when carrying out personal care tasks. The manager explained that he is going to introduce systems that regularly evaluate the service provided and will take action to secure improvements for the betterment of all the residents. What has improved since the last inspection? What they could do better: Poldhu DS0000008920.V252621.R01.S.doc Version 5.0 Page 7 With a new manager designate in post he explained that it is his vision for the home that residents have more control over their lives and feel empowered to make decisions in all aspects of their lives. The aim is for all residents to take an active role in their lives irrespective of their age and frailty but respecting their wishes not to participate if they do not want to. With detailed policies and procedures in place and a move forward to establishing the corporate approach it will be interesting to see the progress being made regarding all staff familiarising themselves with them. 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.V252621.R01.S.doc Version 5.0 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.V252621.R01.S.doc Version 5.0 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 and 4. Residents are given information prior to moving into the home which is sufficient to enable them to make a fully informed choice about where to live. The home demonstrates that it provides training and involves external healthcare professionals to ensure it can meet the needs of the residents living in the home. EVIDENCE: Poldhu DS0000008920.V252621.R01.S.doc Version 5.0 Page 10 Significant work has been undertaken on the Statement Of Purpose and Service User Guide to enable prospective residents and their representative to make an informed decision about where they want to live. I spoke with some residents who said they were provided with relevant information and are actively empowered to choose what they want to do. The management team work effectively with all health care and community professionals with the aim of providing a high standard of care. The Manager said that other health professionals have input as required for example physiotherapists, speech therapists and occupational therapists. Staff have received training in dementia care, diabetes and care of the dying as well as ongoing training courses that underpins their knowledge and skills. The staff said that being a qualified in care gives them a greater understanding of their role and that they are able to care professionally for the residents. Poldhu DS0000008920.V252621.R01.S.doc Version 5.0 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. Detailed written care plans direct and inform staff about how to meet the residents’ health, personal and social care needs. The healthcare needs of residents are thoroughly monitored and addressed so that their needs are met. EVIDENCE: Four residents records were case tracked. Evidence show that the records inspected set out detailed directions and information for staff in care plans for meeting the residents’ healthcare, personal care and social needs. Care plans include risk assessments covering, for example, the risk of falls and environmental risks, and individual risks relevant to each resident. Regular and consistent evaluations of care plans had been recorded with in general the involvement of the residents. Residents were aware in general terms about their care plans. The general frailty of some residents was the reason why staff did not ask for their involvement in agreeing to the records written on them. Nursing staff record daily notes in relation to nursing, personal and social care. Poldhu DS0000008920.V252621.R01.S.doc Version 5.0 Page 12 Care plans detail care procedures and treatments – for example in relation to tissue viability. The care plans and notes record monitoring of healthcare needs and detail contacts with, and input from, GPs, health professionals and tests and investigations. Residents reported that their healthcare needs were well monitored and action taken when required. Medication is well managed but the recording in the CD book should be improved on to detail the correct pages to use. Medicines are stored in locked storage in a designated room. There is a suitable cabinet for controlled drugs and a small refrigerator for medicines. A monitored dosage system is in use. The qualified nursing staff administers medicines. Residents were very positive about the qualities of the staff and the care provided. They stated that staff were competent and sensitive, and respected their privacy and dignity when assisting with care. Residents also reported that staff were friendly and kind, and they felt safe when they were being cared for. Poldhu DS0000008920.V252621.R01.S.doc Version 5.0 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): 12,13,15. Residents enjoy a lifestyle to suit their preferences, their social, emotional and leisure and religious needs. The home ensures that residents have ample opportunity to maintain contact with their family and friends as they wish. Resident’s dietary needs are well catered for with a selection of meals on offer and a waiter service that ensures that residents receive what they wish to eat. EVIDENCE: The aim of the home is to provide the residents with a qualitative experience to and to empower residents to have the opportunity for informed choice to maximise a fulfilled and satisfying life. This is an area that has greatly improved and residents and their relatives talked with me about how much it is enjoyed. The recreational manager has talked with all residents and taken into account a wide variation in preferences and capacity with the result that every opportunity is made to meet individual needs. Detailed records are maintained to evidence what individual residents like to do. Poldhu DS0000008920.V252621.R01.S.doc Version 5.0 Page 14 Poldhu welcomes family and friends at any time as long as this accords with the wishes of the residents. This is stated in the statement of purpose. Residents can entertain visitors in their own rooms or the communal rooms. Residents said that the arrangements for visiting were fine and the management and staff helpful with this. Poldhu is the only home in Cornwall that has a designated waiter service. The first class service to the residents was noted and wine and cold drinks of all sorts were available with dinner.The residents 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. A range of choices is provided for breakfast, which is taken at the residents preferred time. The main meal is served at midday. I sat with the residents in the dining room to have lunch. 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 residents. The residents were unrushed and waiting staff provided appropriate individual attention with the care assistants offering help to residents who required more assistance. Meals can be taken in the dining room; other residents prefer to eat in their own rooms. Management complete nutritional screening assessments on all residents. Poldhu DS0000008920.V252621.R01.S.doc Version 5.0 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. Residents and their relatives are confident that they know the complaints procedure and that their complaints would be listened to and acted upon. There are measures in place to protect vulnerable residents from abuse but these should be strengthened and improved. EVIDENCE: The company have a complaints procedure, which is a clear and accessible procedure, which includes the stages, and timescale for the process and that all complaints are dealt with promptly and efficiently. Residents said to me that they knew how to make a complaint and the staff are clearly aware of the action they are required to take if any complaints are made or any concerns arise about a residents protection. All staff are familiarised with the policy and procedure on complaints and compliments. The home has a written policy for the protection of vulnerable adults from abuse, which is in the process of being updated. Management have revised the policy and procedure to include the role of the local multi-agency procedures and those of the various placing authorities in respect of residents who have been placed there from other authorities. There has been some improvement in the area of Adult Protection training with staff being given in house and some external training. Poldhu DS0000008920.V252621.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,24,26. Recent substantial investment has significantly improved the appearance of the home creating a comfortable and safe environment for residents. The overall quality of the furnishings and fittings is to a very high standard and enables the residents and their relatives to enjoy a pleasing and pleasant environment to live in. The grounds are well maintained, attractive and areas have been established that are safe for residents to use. EVIDENCE: Poldhu DS0000008920.V252621.R01.S.doc Version 5.0 Page 17 There was evidence to show that the commitment to improving the environment continues. Discussion took place with most of the residents 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. Residents said 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 resident’s clothes. The residents 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 residents to access and to be safe weather permitting. Poldhu DS0000008920.V252621.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Staffing levels meet the needs of residents and staff morale is good. The staffing and training arrangements ensure that the needs of residents are met. Recruitment procedures must be tightened up to ensure that residents are supported by the homes recruitment policy and practices. 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 residents can have special time set-aside for them. Care staff are in sufficient numbers to meet the needs of the residents. Poldhu exceeds the 50 level of N.V.Q level two qualification. Staff files inspected did not always contain the documents required by legislation and POVA checks had not routinely been carried out before staff had been offered employment. A review of the recruitment and selection policies and practice must take place to ensure that residents are supported and protected by the homes recruitment practices. This is the second notification for this requirement. Poldhu DS0000008920.V252621.R01.S.doc Version 5.0 Page 19 Poldhu employs a training manager who implements a structured staff-training programme, which supports the aims of the home. The manager has a proactive approach to training for all staff. Staff have a separate training and development file. The staff team are currently updating their mandatory training, which is provided by the company. The residents and their families and friends were very positive about the manner in which the staff undertakes their duties and the care they provide. The staff group have a wide range of skills and abilities to meet the assessed needs and recorded needs of the residents at all times and are clearly committed to providing a qualitative experience for all residents Poldhu DS0000008920.V252621.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36,37,38. The home is well managed; the home’s record keeping and policies and procedures safeguard the residents’ interests but improvement in some areas would further enhance the overall standard of recording. The health and safety of residents and staff are promoted and protected by the new policies and procedures. EVIDENCE: The manager has previous experience as a first level nurse in the health service. He has enrolled on the registered manager award. The Commission for Social Care has received an application to register the manager as the registered manager in law. Poldhu DS0000008920.V252621.R01.S.doc Version 5.0 Page 21 The manager has carried out a quality survey through a questionnaire for residents. It is recommended that as a result of this exercise a systematic cycle of planning –action-review, reflecting the aims and outcomes for residents is compiled. The company have produced Health and Safety Policies and procedures, which details organisational and individual responsibilities for health and safety. It will be interesting to establish what progress has been made in the area of staff familiarisation with the policies and procedures. Records detail regular required checks on fire systems. The fire risk assessment has been completed. All records inspected were up to date and in sufficient detail. Poldhu DS0000008920.V252621.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 3 Poldhu DS0000008920.V252621.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation Sch 2 reg 19 Requirement The recruitment and selection arrangements must be developed to be more robust and meet the requirements in schedule 2. “2nd Notification”. Timescale for action 15/05/06 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 OP9 OP29 OP33 Good Practice Recommendations A new Controlled drugs book should be purchased and strict guidelines to the correct recording should be followed POVA checks should be carried out for all staff before they are employed. The quality assurance exercise should detail a cycle of planning, review and aims and outcomes for residents. Poldhu DS0000008920.V252621.R01.S.doc Version 5.0 Page 24 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.V252621.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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