Inspection on 18/07/07 for Polebank Hall

This inspection was carried out on 18th July 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Polebank Hall 16/05/06

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 18th July 2007 9:30 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 Polebank Hall DS0000005576.V340408.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. Polebank Hall DS0000005576.V340408.R01.S.doc Version 5.2 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 ** Post Vacant *** 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.V340408.R01.S.doc Version 5.2 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) 16th May 2006 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. Polebank Hall is located within a public park. The home 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. Fees for accommodation and care at the home range from £315 to £440. Additional charges are also made for hairdressing and chiropody services, newspapers, personal toiletries and trips. Polebank Hall DS0000005576.V340408.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the key inspection, which included an unannounced site visit. The site visit took place on 18th July 2007 and covered a period of eight and a half hours from 09:30 until 18:00. In addition to this visit the inspector also carried out further random visits. The service had previously completed an annual quality assurance assessment (AQAA) and a data set that gave the inspector certain information about the provision. From these details a selection of service users and their relatives were invited to complete a small survey setting out their comments on identified care issues. As part of the inspection process a selection of individual care plans and assessments were examined. The plans concerned a person who had lived at Polebank Hall for a long time, and a person who had been recently admitted. The inspector also spoke with some residents and their vistors. A tour of the building and observations of care practices and staff interaction was also carried out. The general manager and the home’s acting manager were present during the inspection. Polebank Hall continues to go through an unsettled period however the acting manager has provided continuity of care and has made some effort at meeting the requirements from the previous inspection. What the service does well: What has improved since the last inspection? Work has commenced to improve the appearance of the conservatory and make it useable. Those residents who prefer to read chat or receive visitors without the television are beginning to make better use of the quiet lounge. Polebank Hall DS0000005576.V340408.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Polebank Hall DS0000005576.V340408.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Polebank Hall DS0000005576.V340408.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 intermediate care is not provided at Polebank Hall) Quality in this outcome area is good. Prospective residents have the required information to make an informed choice of where to live and a contract providing the terms and conditions. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The people who live at Polebank Hall have had an assessment of need carried out by either the Social Services department or the National Health Service. The acting 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 at this time with the prospective resident or their family. Polebank Hall DS0000005576.V340408.R01.S.doc Version 5.2 Page 9 A resident described to the inspector how she had visited the home and viewed the accommodation before she made a decision to move in. Polebank Hall DS0000005576.V340408.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. The care plans fail to represent the resident’s individual needs and to provide the carers with the information they need to ensure all aspects of care are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Issues concerning reviewing and monitoring of the individual care plans have been identified at previous inspections. During this inspection a care plan belonging to a recently admitted person was examined. It is acknowledged that there had been some attempt to improve the documentation and to make this plan more person centred. There was no personal social history and the risk assessment was limited in its content. Polebank Hall DS0000005576.V340408.R01.S.doc Version 5.2 Page 11 This is an important document that needs to be completed in a considered manner preferably with the resident or their representative. It should provide the carers with up to date information in order that all aspects of health, personal and social care could be met. A resident wrote in a survey that she only sometimes received the care and support she needed adding, “Although I am supposed to be receiving full assistance with my personal care, staff are not always aware of this and do not always provide the necessary level of support. I have complained about this recently and there has been some improvement.” One resident and two visitors were not aware of the care planning or reviewing process when they spoke with the inspector. A local general practitioner noted in a survey there are “good standards of overall care.” A medication policy and procedure is in place. A local pharmacist provides a monitored dosage system and the senior staff have received the appropriate training to administer medication. Observed practice was satisfactory as is the medication storage. The residents who spoke with the inspector said they had their medication given to them by the staff and one person said they were aware they could do this themselves if they chose to. The inspector observed carers supporting a resident who was no longer able to stand. The carers were using a mobile hoist to manoeuvre the resident into a wheelchair. The carers talked calmly to the resident explaining the reasons for the hoist and calming the residents’ fears. They showed great empathy and respect whilst preserving the residents dignity at this time. Polebank Hall DS0000005576.V340408.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. The residents are enabled to live a fulfilled life and are provided with a balanced and nutritional menu, thereby promoting good health. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the previous inspection it was noted that an area of the care planning document was designed to be completed by the individual or their family. This concerned their social history and previous lifestyle. This situation had not been addressed as required. The documentation concerning the residents’ previous lifestyles and social history is considered to be important. By obtaining such information the carers will have a clearer understanding of individual aspects of behaviour. The carers should also be able to provide an individualised service that recognises the residents’ diverse needs. Polebank Hall DS0000005576.V340408.R01.S.doc Version 5.2 Page 13 It was apparent from speaking to the carers that the resident’s relatives were well known and welcome to the home. Based on observation the visitors were at ease with the staff and the other residents. The inspector spoke with two relatives who were visiting the home; they confirmed that they were in general happy with the care their relative was receiving. One person stated that she did not think there was enough stimulation throughout the day for her relative. There is no regular programme of activities provided at the home and no dedicated activities organiser. This was recognised within the details forwarded to the inspector before the inspection. During the afternoon of the inspection carers could be seen sitting chatting with some of the residents. Better use is now being made of the quiet lounge. This has now enabled those residents who want to read the newspapers, chat and in one case complete a crossword to do so without the distraction of the television. Visitors also said it was an improvement and benefit for their relative. A resident told the inspector that she derived great comfort from regular visits by lay visitors who brought her communion, from her church. She said she would love to be able to attend the services at the church but recognised this was no longer possible. A notice within the home displayed dates for other religious visits. The acting manager said that they had not had as many trips this year due in part to the poor weather. There were however, eight people going to a dance and bingo session the next evening. This was to be provided by a local organisation that was also laying on the transport. Some staff and relatives were also going to support the residents at this time. Those residents who spoke to the inspector said they felt they could go to bed when they wanted to and also get up in their own time. One resident said no in response to the question, do the staff listen and act on what you say? This person also noted; “Sometimes my views are taken into account and acted upon but this does not always happen.” The inspector observed the lunchtime meal. Some residents had chosen to have a hot meal and others had a sandwich with salad garnish. The meal was taken at a leisurely pace with the staff conducting themselves in a relaxed manner. Two residents said they had enjoyed their meal and confirmed in general the quality of the meals was good. Polebank Hall DS0000005576.V340408.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. The home has a satisfactory complaints system with evidence that residents feel that their views are listened to and acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A safeguarding adults investigation has been completed as a result of a visitor complaining about discrepancies in two residents’ finances. The providers of the service reacted in a professional manner to protect the resident’s interests during the investigation. The inspector had carried out a random visit to check on the situation concerning the ongoing safeguarding adults investigation and to make sure the financial records were being appropriately maintained. The people who spoke with the inspector during this inspection said they would speak to the acting manager if they had any complaints or concerns. They said they were confident that the acting manager would listen to their complaints and act upon them. One resident noted in her survey form that she had complained recently and had noticed an improvement as a result. Polebank Hall DS0000005576.V340408.R01.S.doc Version 5.2 Page 15 The senior staff have received training in the Protection of Vulnerable Adults (POVA). POVA training for the other staff has lapsed. According to the documentation provided by the home before the inspection, a reason for this was due to the turnover of staff. Polebank Hall DS0000005576.V340408.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. Polebank Hall provides the residents with a warm, welcoming home. There are high standards of housekeeping and general maintenance. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It is understood that Polebank Hall is a listed building located in the centre of a public park. Internally it retains all the splendour associated with an English country house. The registered provider leases the building from the local authority. The responsibility for the upkeep of the external building continues to remain unresolved and in the mean time the overall condition continues to deteriorate. Polebank Hall DS0000005576.V340408.R01.S.doc Version 5.2 Page 17 A resident has recently had to be provided with alternative accommodation as a result of rainwater penetrating her room making it uninhabitable. At the time of this inspection work was being carried out to dry the room and redecorate where necessary. There was evidence in other rooms that rain water had also penetrated the ceilings. The inspector was advised that repairs have been carried out to this area of the roof. Work has commenced to improve the conservatory (also understood to have listed building status) in order that it can once again be safely used. The interior of the building is maintained to a good standard. Areas of the home have been decorated and those residents who spoke with the inspector said they liked living at Polebank Hall. The home was warm and welcoming with high standards of cleanliness. A relative noted in the survey; “The food is good the staff are compassionate and Polebank doesn’t smell! Which tells me it’s very clean.” Polebank Hall DS0000005576.V340408.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. The turnover of staffing is impacting on the continuity of care for the residents who feel there are at times inadequate numbers of carers to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection a new rota has been introduced. This was to provide a more even coverage of staff over the waking working day. The inspector examined the rota. The numbers of staff on duty and observed to be working during the inspection appeared appropriate to the needs of the residents at this time. It is understood that interviews for carers continue to take place. It is recognised by the managers that there has been a high turnover of staff. There remains a core group of people who have worked at Polebank for some considerable time thereby providing consistency for the residents. Discussions took place with the managers regarding unreliability of a small number of staff and sickness records. Polebank Hall DS0000005576.V340408.R01.S.doc Version 5.2 Page 19 One person commented in response to the question, are staff available when you need them? “There are frequently staff shortages especially at night, meaning that staff are not always available when needed.” Further on in this survey the same resident noted, “There is a very large turnover of staff at the home with a large number of inexperienced and untrained people being employed.” A further comment from a relative noted in response to, how do you think the care home can improve? “The manageress does a great job, but staff shortages do cause problems.” A visitor also commented about the staffing in particular that the “younger ones don’t stay very long.” It is of some concern that the residents and their visitors have commented in this manner. Whereas it is recognised that perceived or actual, the staffing numbers and skill mix may now be having a detrimental impact on the residents’ wellbeing. The managers are recommended to address this situation. Requirements concerning the formal induction training to meet with the Skills for Care system have not been carried out, although it is understood newly employed staff have a period of induction training within the home. This is mainly involving aspects of health and safety. The ratio of carers with a National Vocational Qualification at level 2 has lapsed due in part to the staff turnover. The mandatory health and safety training is carried out within the home. The home also continues to purchase training for the staff through the training consortium. Records were in place to confirm training places. It was confirmed there have been no changes to the recruitment and selection processes that have previously been considered to be robust. Polebank Hall DS0000005576.V340408.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. The absence of a registered manager is causing the home to lack direction and leadership. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is no registered manager currently in post. The vacancy has been advertised in the local press and interviews have taken place. The acting manager has worked hard to maintain continuity of the service following the previous managers departure. Polebank Hall DS0000005576.V340408.R01.S.doc Version 5.2 Page 21 The home is run in the best interests of the residents but lacks direction due to the absence of an experienced manager. The people who talked with the inspector spoke highly of the acting manager and other staff. Polebank Hall has gone through a period of uncertainty and disruption but with an appropriate person in charge should be back on an even keel once the requirements contained in this report are fully addressed. As previously documented within this report (standards 16-18) systems to maintain the residents’ finances have been improved. During the inspection work was being carried out on the conservatory. This area can be accessed from a lounge area. Whilst this work is being carried out it is vital that the residents are not able to walk into the area and be at risk from injury. This situation was brought to the manager’s attention during the inspection. A relatives survey response described an accident in the home that had been poorly managed by the person in charge at the time. The accident had resulted in the resident receiving a fracture. This situation was discussed with the manager and the accident report was examined. It is accepted by the general manager that the incident had failed to be managed correctly and the relative had been informed of this. The member of staff had also been formally spoken with. 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.V340408.R01.S.doc Version 5.2 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 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Polebank Hall DS0000005576.V340408.R01.S.doc Version 5.2 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 OP7 Regulation 15(2) Requirement The registered person must ensure the care plans are completed in enough detail to enable the carers to provide individualised care. The care plans must also be monitored and reviewed at regular intervals and in conjunction with the individual resident or their representative. (Previous time scales 01/12/06 & 01/05/07 not met and still apply). 2. OP30 18(1)(a)( b) The registered person must 18/07/07 ensure that all newly employed staff receives induction training to meet the NTO specifications within the first six weeks of appointment. (Previous timescales of 01/12/06 & 01/06/07not met and still apply). The registered person must ensure the newly appointed manager applies to the CSCI to be registered as a fit person and enrols on the NVQ 4 registered mangers award. DS0000005576.V340408.R01.S.doc Timescale for action 18/07/07 3. OP31 9(1)(2)(a) (b)(c) 01/09/07 Polebank Hall Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The registered person should ensure the care plans are more person centred. The care plans should also make reference to assessments carried out under the Mental Capacity Act (2005). The registered person should ensure the residents’ social histories and previous lifestyles are identified and documented. The registered person should make sure the ratio of carers with an NVQ at level 2 is improved. 2. OP12 3. OP28 Polebank Hall DS0000005576.V340408.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Polebank Hall DS0000005576.V340408.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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