CARE HOMES FOR OLDER PEOPLE
Polebrook Nursing & Residential Home Polebrook Nursing Home Morgans Close Polebrook Oundle Cambs PE8 5LU Lead Inspector
Mrs Sarah Smart Unannounced Inspection 11th October 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 Polebrook Nursing & Residential Home DS0000012633.V257814.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. Polebrook Nursing & Residential Home DS0000012633.V257814.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Polebrook Nursing & Residential Home Address Polebrook Nursing Home Morgans Close Polebrook Oundle Cambs PE8 5LU 01832 273256 01832 741970 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) Birchester Medicare Limited Mrs Helen Russell Care Home 51 Category(ies) of Dementia - over 65 years of age (51), Old age, registration, with number not falling within any other category (51), of places Physical disability over 65 years of age (51), Terminally ill over 65 years of age (51) Polebrook Nursing & Residential Home DS0000012633.V257814.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. Convalescent Day Care (10 places) To provide care for one named service user under the age of 65 years. The total number of service users must not exceed 51. Date of last inspection 25th April 2005 Brief Description of the Service: Polebrook Residential and Nursing Home is a large purpose built home situated in the village of Polebrook. The home can be found at the end of a small culde-sac, set in large grounds. The home offers all ground floor accommodation, with a mixture of single and double rooms, the majority of which have ensuite facilities. The home has several communal rooms and a large conservatory area. Polebrook Nursing & Residential Home DS0000012633.V257814.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. An unannounced inspection was undertaken between the hours of 9.30am and 2.30pm. Preparation for the inspection included, review of the last inspection report, and previous requirements, and took approximately 2 hours. The primary method of inspection used was ‘case tracking’. This involves selecting a number of service users and tracking their care and experiences through review of their records, discussion with them, the care staff and observation of care practices. The following areas were covered during the inspection: case tracking, medication, sample of policy review, staff rota, staff supervision, previous requirements made, and staff and service user interviews. Three service users were case tracked. Two staff members, plus the manager, were interviewed at length, and several others briefly, whilst three service users were spoken to in detail. What the service does well: What has improved since the last inspection?
Healthcare assessments had improved, although two were totalled incorrectly. The previous requirement in relation to medication had been met. The prevision of activities has been addressed. Polebrook Nursing & Residential Home DS0000012633.V257814.R01.S.doc Version 5.0 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. Polebrook Nursing & Residential Home DS0000012633.V257814.R01.S.doc Version 5.0 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 Polebrook Nursing & Residential Home DS0000012633.V257814.R01.S.doc Version 5.0 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): 1,3 Service users are adequately informed, and assessments recorded adequately. EVIDENCE: The statement of purpose had been submitted to the Commission for Social Care Inspection following a requirement made at the previous inspection. The document was satisfactory. Assessments were noted to be thoroughly completed, and contained valuable information. The assessments included identification of risks. Polebrook Nursing & Residential Home DS0000012633.V257814.R01.S.doc Version 5.0 Page 9 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): 7,8,9,10,11 Service users health and personal care needs are met. One medication issue must be addressed. EVIDENCE: Care plans were written to a high standard. In a few instances the care plans were not completely up to date, however the manager stated that the changes had only occurred in the last 24 hours. In only one instance two care plans did not correspond in one piece of information, and one daily summary gave information which conflicted with the care plan. Due to the acceptable quality of the majority of the information, a requirement has not been made in relation to these issues. The standard of healthcare assessments had improved considerably since the last inspection. Two assessments had not been totalled correctly, and one assessment had been added to by a member of staff in the home, which completely altered the structure and use of the form. The inspector recommends that if the initial form is not suitable, then an alternative should be sought. A sample of medication was viewed. Whilst the previous requirement in relation to medication had been met, in one instance a tablet remained
Polebrook Nursing & Residential Home DS0000012633.V257814.R01.S.doc Version 5.0 Page 10 ungiven in the storage system, however the medication administration record sheets were signed to indicate that it had been given. Dressings in use were not detailed on the medication administration record sheets. The staff stated that dressings are initially supplied by the tissue Viability Nurse. The inspector recommends that these are written onto the medication administration record sheets and signed when used. Staff were observed providing care to the service users during the inspection, and service users were spoken to. At no time was service users privacy or dignity not respected. Staff were noted to have a very pleasant manner with the service users in their care. The death policy was viewed. This was written to an acceptable standard, and contained all of the required information. Service users wishes in the event of their death was recorded. Polebrook Nursing & Residential Home DS0000012633.V257814.R01.S.doc Version 5.0 Page 11 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 The provision of activities has improved. EVIDENCE: The inspector was advised that an activities organiser has now been employed in the home. There was evidence of various activities that had been held. The inspector noted that one service user has her dog visit her in the home regularly. Polebrook Nursing & Residential Home DS0000012633.V257814.R01.S.doc Version 5.0 Page 12 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 and 18 partially Complaints and adult protection is handled appropriately. EVIDENCE: The complaints policy was viewed. The policy must advise the reader that the Commission for Social Care Inspection can be contacted by a complainant at any time. Staff demonstrated a satisfactory knowledge of the complaints process. The abuse policy was separated into two parts, neither of which referred to the other, meaning that the reader may miss valuable information. It is recommended that the documents are either combined, or refer the reader to each other in some way. Staff demonstrated a satisfactory knowledge of the Protection of Vulnerable Adults procedure. Polebrook Nursing & Residential Home DS0000012633.V257814.R01.S.doc Version 5.0 Page 13 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 The environment of the home is well maintained, however one staff member must be reminded of infection control measures. EVIDENCE: The entrance hall and reception area, including nurse station have been totally refurbished since the last inspection. This has been done to a high standard, and offers a very welcoming area, and work area for the staff. The home was very clean and tidy at the time of the inspection. The manager advised that a team of cleaners are employed, who provide an acceptable level of service. One staff member was observed to provide hand and nail care to service users without cleaning the equipment used, changing her gloves, or washing her hands between each service user. This was brought to the attention of the manager. Polebrook Nursing & Residential Home DS0000012633.V257814.R01.S.doc Version 5.0 Page 14 The inspector was advised that an Environmental Health Officer had visited the home the preceding week, at which time some issues were identified. The manager stated that the issues had already been addressed. Polebrook Nursing & Residential Home DS0000012633.V257814.R01.S.doc Version 5.0 Page 15 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 Staffing levels are adequate. EVIDENCE: The staff rota demonstrated that the early shift is covered by one or two trained nurses, and seven or eight care staff, whilst the late shift is worked by one or two nurse and 5 carers. The night shift is covered by one nurse and three carers. The manager stated that the staffing levels are calculated according to the dependency levels of the service users in the home. Polebrook Nursing & Residential Home DS0000012633.V257814.R01.S.doc Version 5.0 Page 16 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): 31,36,37,38 The management of the home has improved to an acceptable standard. EVIDENCE: The manager has completed her fit person process and is registered with the Commission for Social Care Inspection. The inspector recognises that the manager has contributed, and encouraged and empowered staff, to improve the provision of care and overall management of the home. The manager stated that a structure for staff supervision has been introduced, and that all staff are receiving regular, and recorded, supervision. Risk assessments were written to an acceptable standard. In two instances consent had not been obtained for the use of bed rails, however risk assessments had been written. Polebrook Nursing & Residential Home DS0000012633.V257814.R01.S.doc Version 5.0 Page 17 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 3 3 2 Polebrook Nursing & Residential Home DS0000012633.V257814.R01.S.doc Version 5.0 Page 18 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 8 Regulation 12(1) Requirement Healthcare assessments must be totalled and recorded correctly, in order that risks are identified at the earliest opportunity. This is a previous requirement which remains unmet. Recording of medication must be accurate. The manager must demonstrate that appropriate action has been taken with the staff member responsible for this error. A cross infection risk must be addressed. Timescale for action 31/10/05 2 9 13(3) 25/10/05 3 26 13(3) 25/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard 16 18 Good Practice Recommendations The complaints policy should state that the Commission for Social Care Inspection can be contacted by the complainant at any time. The two abuse policies should be combined, or make
DS0000012633.V257814.R01.S.doc Version 5.0 Page 19 Polebrook Nursing & Residential Home 3 4 5 38 8 9 reference to each other. Service users consent for the use of bed rails should be obtained. Healthcare assessments should be appropriate for their use, and not adapted by the staff. Dressings should feature on the medication administration record sheets. Polebrook Nursing & Residential Home DS0000012633.V257814.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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