Inspection on 16/05/06 for Polebank Hall

This inspection was carried out on 16th May 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

Polebank Hall 18/07/07

Polebank Hall 13/12/05

Polebank Hall 22/06/05

Polebank Hall 21/01/05

Polebank Hall 19/08/04

Polebank Hall 24/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Polebank Hall Stockport Road Gee Cross Hyde Tameside SK14 5EZ Lead Inspector Janet Ranson Unannounced Inspection 09:00 16th May 2006 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 Polebank Hall DS0000005576.V289852.R01.S.doc Version 5.1 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. Polebank Hall DS0000005576.V289852.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Polebank Hall Address Stockport Road Gee Cross Hyde Tameside SK14 5EZ 0161 368 2171 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) Polebank Residential Care Home Limited Care Home 29 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (29), Old age, not falling within any other category (29), Physical disability over 65 years of age (16), Sensory Impairment over 65 years of age (3) Polebank Hall DS0000005576.V289852.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users up to 24 (DE) (E); up to 3 (SI) (E); up to 29 (MD) (E); up to 29 (OP) and up to 16 (PD) (E) 13th December 2005 Date of last inspection Brief Description of the Service: Polebank Hall is a large detached property situated in the centre of a public park. Formerly a mill owner’s house, it now has listed building status. The building is in a poor state of repair. The property has been adapted and extended over the years to provide accommodation on three floors in 25 rooms, 11 of which have en-suite facilities, and two shared rooms both with en-suite facilities. The lounges and dining room are on the ground floor. There is also a large conservatory to the side of the building. This is waiting for listed planning permission to be upgraded and made comfortable for the residents. Although Polebank Hall is located within a public park it does not have a secure garden space dedicated for the residents’ use. It would appear this does not have a detrimental effect on the residents who take great delight in watching the comings and goings of the general public who also use the area. Polebank Hall DS0000005576.V289852.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Polebank Hall provides personal care for up to 25 residents over 65 years of age. This was an unannounced inspection carried out over eight and a half hours. At the time of the inspection there were three vacancies with an expectation that a person was going to be admitted the following day. Present for the majority of the inspection was the acting manager and the assistant manager. Three individual care plans and assessments were examined as part of the inspection process. The plans selected concerned a person who had lived at Polebank Hall for a long time, and two people who had been recently admitted. A total of three residents spoke of their experiences of living at the home. A further three relatives and three staff also assisted the inspector with their comments. A tour of the building both internally and externally and observations of care practices and interaction was also carried out. Polebank Hall continues to go through a period of change as a result of the long established registered manager and her deputy leaving their posts and a further two appointed managers resigning their posts within a short period. The newly appointed manager and her assistant were previously team leaders and have worked hard together to recreate a level of stability and continuity. The kitchen staffing has also regained stability with the resident’s commenting more positively on the quality of the meals. Decoration to the main communal areas and some bedrooms has been carried out to good effect since the previous inspection, whilst the external features of the building continue to deteriorate. Paint on some window frames and decorative wall features is none existent and the conservatory is looking distinctly shabby. It is understood that the registered person continues to seek clarity as to the responsibility for the external upkeep of the building, believing it to be that of the local authority. The home employs housekeepers, catering staff, laundry personnel and a maintenance man in addition to teams of carers. What the service does well: Polebank Hall DS0000005576.V289852.R01.S.doc Version 5.1 Page 6 Polebank Hall meets with the resident’s aspirations. A relative said she felt loved and cared for when she visited the home and had great trust in the staff and their abilities. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Polebank Hall DS0000005576.V289852.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Polebank Hall DS0000005576.V289852.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the required information to make an informed choice of where to live and a contract providing the terms and conditions. Standard 6 intermediate care is not provided at Polebank Hall EVIDENCE: In the course of this inspection three files including long-standing residents and those of recently admitted people were examined. They all included an assessment of need carried out by either the Social Services department or the National Health Service. The manager stated that she usually visited the prospective resident prior to their admission to introduce herself, describe the service and confirm the home can meet their needs. A service user’s guide would be left with the prospective resident or their family. Polebank Hall DS0000005576.V289852.R01.S.doc Version 5.1 Page 9 The residents who spoke with the inspector were not able to recall the process of assessment. One visitor described how she had visited the home on her relative’s behalf to “see for herself”. Polebank Hall DS0000005576.V289852.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a good standard of care but there needs to be involvement with the resident’s (or their representatives) in the review and monitoring. EVIDENCE: During the course of the inspection three care plans were examined. The care plans were found to be maintained in good order and set out in detail individual care and health needs. Individual weight records and visits from health professionals were held in separate records. Whereas there was evidence within the care plans that the manager had reviewed them, none of the resident’s representatives had been involved in the planning of care and were unaware of the reviewing process. From observation of staff practice it was apparent that the residents were treated with great respect. Two carers were practicing distraction techniques with two residents who were particularly restless and in one case distressed. The carer’s calmness and empathy was appropriate to the situation allowing the resident levels of dignity. Polebank Hall DS0000005576.V289852.R01.S.doc Version 5.1 Page 11 The residents were appropriately dressed and cleanly presented. They also appeared to be comfortable and well cared for. A relative stated she felt loved and cared for by the staff, and by assisting her relative to bed remained involved with his care. She confirmed they had privacy during her visits and felt her husband was treated with respect. Three medication administration records (MAR) were examined and found to be completed in the approved manner. Medication storage was appropriate and all the senior staff responsible for the administration had recently undertaken refresher training. The home uses a monitored dosage system provided by a local pharmacist. It was reported by the senior staff that the pharmacist provided them with a good service and support when required. The policy and actions concerning residents who want to self medicate was satisfactory. Polebank Hall DS0000005576.V289852.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are enabled to live a fulfilled life and are provided with a balanced and nutritional menu, thereby promoting good health. EVIDENCE: It was noted at the previous inspection a newly appointed carer had been made responsible for a programme of activities. This was no longer the case. There was photographic evidence of themed days, (Easter, Saint Patrick’s day) displayed in the hallway. A short game of skittles took place before lunch in an attempt to involve those resident’s who were becoming restless. A resident was observed to be putting bread out on the bird table in the side garden. A senior member of staff explained that the team leaders had been relocated to a more visible area of the home so that a greater level of supervision could take place. This included practices to defuse potential incidents such as the spontaneous game of skittles. An area of the care planning document was designed to be completed by the individual or their family, it concerned the social history and previous lifestyle. In the care plans examined during the inspection this had not been completed. Polebank Hall DS0000005576.V289852.R01.S.doc Version 5.1 Page 13 The documentation concerning the resident’s previous lifestyles and social history is considered to be important. By obtaining such information the carers may identify and address individual issues of concern. Visitors could be seen in the home throughout the inspection, they were treated courteously and made to feel welcome. The visitors two of whom daily attended the home confirmed this to the inspector. They also commented that they felt able to use most parts of the home for greater privacy. The resident’s spiritual needs are met by regular visits from the various local churches. It was reported that one resident derives great comfort from the priest’s visits. The daily menu with options was displayed in the main hallway. Carers go around the home each evening to ascertain the individual choice of meals for the following day. A new chef had been appointed since the previous inspection and according to the residents the quality of the meals had greatly improved. The chef is knowledgeable and is able to provide for the resident’s various likes, dislikes and dietary requirements. He has recently attended a training course concerning nutrition for elderly people. In discussion the chef stated he served the lunch and evening meal in order that he can see how the meals have been received and to be available for comments. He has made some changes to the menu but recognises that plainer food is the order of the day. The content of the menu appeared balanced The newly decorated dining room is well appointed with tables invitingly set for small groups of residents. It was observed that some residents had chosen to eat elsewhere in the home. Polebank Hall DS0000005576.V289852.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s complaints procedure and staff training provides protection to the people who live at Polebank Hall. EVIDENCE: The records concerning complaints and complements were examined and it was further noted that a copy of the home’s complaints procedure was contained within the service users guide. In discussion relatives and resident’s said they would report any concerns to the manager with the expectation that they would be addressed. One person had made a complaint concerning her mother’s personal care, which had been addressed. The home has a policy and procedure to respond to allegations of abuse with links to the local authorities protocols. In discussion, a carer demonstrated there awareness of abuse and described how they would report concerns to the manager or registered provider. A programme of formal training in the Protection of Vulnerable Adults (POVA) has commenced for staff at all levels. Polebank Hall DS0000005576.V289852.R01.S.doc Version 5.1 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 the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Polebank Hall provides the residents with a warm, welcoming home. There are high standards of housekeeping and general maintenance although the initial impression of the building is very poor. EVIDENCE: It is understood that Polebank Hall is a listed building located in the centre of a public park. The responsibility for the upkeep of the external building remains unresolved and in the mean time the overall condition continues to deteriorate. Paintwork on window frames and other areas of woodwork is none existent. The conservatory was looking very shabby and the manager voiced her concerns as to its safety. In general the whole external appearance gives a poor impression. Garden beds to the front of the home are usually planted up by the parks department and were looking past their best but a resident confirmed they had Polebank Hall DS0000005576.V289852.R01.S.doc Version 5.1 Page 16 been very pleasant. There is a mixture of park benches and benches belonging to the home located at the front, tables and parasols are also available during the better weather. This area is also a car park for the general public visiting the home and the park. At the time of the inspection the small enclosed garden to the side of the building was overgrown and full of weeds although a resident said the local parks staff had cut the grass recently. There was also confusion as to the “ownership” of this area, which would provide greater privacy and security for some of the more vulnerable residents. Internally the registered person has addressed the requirements concerning redecoration of the communal areas. The condition of the dining room is much improved and the problems of water penetration on the ceiling remedied. A landing on the first floor has also been redecorated making this area brighter. Some bedrooms have been redecorated and soft furnishings upgraded. The resident’s rooms are nicely personalised. Polebank Hall retains all the splendour associated with an English country house. Housekeeping standards are usually very high as noted by the inspector and confirmed by some residents and visitors. although a smell of stale urine was detected in one bedroom. The resident’s who spoke with the inspector stated they were pleased with the redecoration and satisfied with their accommodation. A maintenance man has been employed since the last inspection. He is responsible for the day-to-day repairs. Polebank Hall DS0000005576.V289852.R01.S.doc Version 5.1 Page 17 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 using available evidence including a visit to this service. The numbers and skill mix of the staff meet with the residents identified needs. EVIDENCE: The rota was examined as part of the inspection process. It documents the numbers of carers, housekeepers, laundry and catering staff on duty at any one time. Judging from this information and from observation on the day it was apparent that there was enough carers to meet the resident’s identified needs. The cleanliness of the home bore evidence there were enough housekeepers and the kitchen had dedicated chef and assistance every day. The residents confirmed they were happy with the staffing levels and visitors stated the levels had improved. One visitor said he thought there was a high staff turnover but there was no evidence to support this at this time although it was recognised there had been an unsettled period. One resident said “they will do any thing for you” and of particular note “they will make you a cup of tea during the night if you can’t sleep”. A person had phoned the Commission for Social Care Inspection to say that on a certain date and time care staff numbers were inadequate to meet the resident’s needs. There was no evidence to support this allegation and records Polebank Hall DS0000005576.V289852.R01.S.doc Version 5.1 Page 18 showed a ratio of four carers from 8am and between 3 or 4 during the afternoon. The home remains committed to the National Vocational Qualification (NVQ) training system at levels 2 and 3. Distance learning packages have also been completed concerning health and safety issues, infection control, medication administration and nutritional requirements. The manager has also taken advantage of courses concerning dementia awareness. A senior member of Laurel Bank staff carries out the manual handling training being an accredited trainer. A selection of staff files was examined. They were found to contain the required documents appertaining to references and CRB checks and evidence of identity. The only reference to induction training was a checklist concerning health and safety issues carried out during the first day of appointment. This does not meet with the National Training Organisation specifications and the registered person is required to address this issue. Polebank Hall DS0000005576.V289852.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are good systems to ensure the health, safety and welfare of the residents, visitors and staff. The home does not provide a system of regularly seeking the resident’s views, which would provide them with the opportunity to contribute towards the service. EVIDENCE: The newly appointed manager has commenced the process of registration with the Commission for Social Care Inspection as required. She was a team leader under the previous managers. She has made good start at addressing the requirements made at the previous inspection and has the support of the Polebank Hall DS0000005576.V289852.R01.S.doc Version 5.1 Page 20 assistant manager and team leaders. The staff that spoke with the inspector said the home was more settled than had been the case with the previous managers. Lines of communication have also improved and there are regular staff meetings and formal supervision. Access to mandatory training has improved and now complies with the requirements made at the last inspection. There is no formal method to ensure the resident’s or (their representatives) views of the service are obtained and acted upon. Advice was offered to the manager concerning this issue. Small amounts of personal allowances are retained for safekeeping. Records of expenditure with receipts are retained for inspection purposes. The financial director regularly audits these records. Policies and procedures are in place to ensure the health, safety and welfare of the residents, the visitors to the home and the staff. Aids and adaptations are provided to enable the residents to move safely around the home. The fire precautions and signage were found to be in order. Polebank Hall DS0000005576.V289852.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Polebank Hall DS0000005576.V289852.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation Requirement Timescale for action 01/07/06 15(2)(b)(c The registered person must ) ensure the care plans are monitored and reviewed at regular intervals and in conjunction with the individual resident or their representative. The registered person must ensure the social history and previous lifestyles are identified and documented. 23(2) The registered person must ensure the external appearance of the home is maintained to a good standard. 13(4)(a)(c The registered person must ) ensure the conservatory is maintained in a safe condition. 18(1))a)( The registered person must b) ensure that all newly employed staff receive induction training to meet the NTO specifications within the first six weeks of appointment 9(1)(2)(a) The registered person must (b)(c) ensure the newly appointed manager applies to the CSCI to be registered as a fit person and enrols on the NVQ 4 registered DS0000005576.V289852.R01.S.doc 2. OP12 16(12) 01/07/06 3. OP19 01/10/06 4. 5. OP19 OP30 01/07/06 01/07/06 6. OP31 01/07/06 Polebank Hall Version 5.1 Page 23 mangers award. 7. OP33 24(1)(a) (b)(2)(3) The registered person must ensure there is a system of seeking the resident’s views of the service. 01/08/06 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 Refer to Standard OP19 Good Practice Recommendations The registered person should provide the commission with a plan to address the continued deterioration of the building. Polebank Hall DS0000005576.V289852.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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. 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