Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 23/04/07 for Polebrook Nursing & Residential Home

Also see our care home review for Polebrook Nursing & Residential Home for more information

This inspection was carried out on 23rd April 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The staff team were responsive to residents` needs and presented as being caring and committed. At the time of the inspection regular staff rather than agency staff covered all shifts providing consistency of care. Staff spoken with had worked at the home for several years and had a good knowledge of residents` individual needs. There are good links and relationships with healthcare professionals, which helps to ensure that residents` healthcare needs are met. Residents` and their relatives are involved in decision making about their healthcare, and residents`, a relative and a healthcare professional spoken with were happy with the overall care provided. Visiting arrangements and times are flexible and visitors are made to feel welcome. A comfortably furnished and `homely` room has been set aside for use by residents` who wish to have a private visit with their relatives and do not wish to use their bedroom. The room is large enough to accommodate several family members at a time. All areas of the home were clean and fresh. Bedrooms are comfortably furnished and residents` are encouraged to treat Polebrook as their home and to bring personal pictures and belongings into their room to create a `homely` and familiar environment.

What has improved since the last inspection?

Improvements have been made to the management of medication since the last inspection. Regular audits of the medication are carried out by the registered manager, enabling any discrepancies to be quickly identified and addressed reducing the risk to residents. Staff have received training in infection control since the last inspection and the registered manager confirmed that the practice of using the same container of hand cream for all residents for hand massage had been discontinued to reduce the risk of the spread of infection.

What the care home could do better:

While the overall management and organisation of the care provided appeared to be very good the apparent failure to take action to comply with a requirement made a year ago to protect residents from the risk of burns from heaters gives cause for concern about the health and safety of residents. A dip in the floor on one of the corridors, which is difficult to see due to being covered in carpet, needs attention to reduce the risk of falls.Improvements to the recruitment procedure are required to ensure that all required checks are made in all cases, and that a full employment history is obtained to ensure that residents` are properly protected.

CARE HOMES FOR OLDER PEOPLE Polebrook Nursing & Residential Home Polebrook Nursing Home Morgans Close Polebrook Oundle Cambs PE8 5LU Lead Inspector Mrs Kathy Jones Key Unannounced Inspection 23rd April 2007 08:40 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.V334429.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. Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 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 Birchesterplc@yahoo.co.uk helenrussellrgn@AOL.com Birchester Medicare Limited 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) 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) Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. To provide care for one named service user under the age of 65 years The total number of service users accommodated at Polebrook Nursing and Residential Home must not exceed 51 To be able to admit the named person of category OP (under 65 years) named in variation application no. V34916 dated 7th September 2006 6th August 2002 Date of last inspection Brief Description of the Service: Polebrook Residential and Nursing Home is a fifty one bedded purpose built care home located in the village of Polebrook, which is three miles from the town of Oundle. Birchester Medicare Ltd own the home. The home provides for older people requiring personal care, nursing care or dementia care. The accommodation is all located on the ground floor, with a mixture of single and double rooms, the majority of which have en-suite facilities. The home has several communal rooms and a large conservatory area. The following fees were provided by the registered manager as being current on 23 April 2007. Local Authorities who are funding residents are charged at their set rate of £331.60 to £336.94 depending on assessed needs. A £50 weekly ‘top up fee’ is payable by the resident. Privately funded residents are charged between £545 and £575, with those requiring nursing care charged between £575 and £600 dependent on assessed need. The fees include personal care and where applicable nursing care, meals and accommodation. Chiropody, hairdressing services, and newspapers can be arranged and are charged separately. Other costs would include clothing and toiletries. Currently the cost of chiropody treatment is £9 and hairdressing ranges between £6-50 and £18. Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Standards identified as ‘key’ standards and highlighted through the report were inspected. The key standards are those considered by the Commission to have a particular impact on outcomes for residents. Inspection of the standards was achieved through review of the information held by the Commission for Social Care Inspection as part of the pre-inspection planning and an unannounced inspection visit to the service. The preinspection planning was carried out over the period of half a day and involved reviewing the service history, which details all contact with the home including notifications of events reported by the home, telephone calls, letters, and details of any complaints and concerns received. The report from the last inspection carried out on 7th April 2006 was also reviewed and the findings taken into account when planning this inspection. A pre-inspection questionnaire submitted by the registered manager in November 2006 provided information, which has been taken into account as part of the inspection. The views of four residents and a health professional who forwarded completed questionnaires have also been reflected in this report. The registered manager confirmed that questionnaires had been made available to relatives, however no responses had been received at the time of inspection. The unannounced inspection visit covered the morning and afternoon of a weekday. The inspection was carried out by ‘case tracking’ which involves selecting residents’ and tracking their care and experiences through review of their records, discussion with care staff and observation of care practices and the environment. The inspector spoke with several residents throughout the inspection, a relative and a health professional. Observations were made of their general well being, daily routines and interactions between staff and residents. Records reviewed included a sample of staff files to check the adequacy of the recruitment procedures. The findings of the inspection were discussed with the registered manager at the time of the inspection. Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: While the overall management and organisation of the care provided appeared to be very good the apparent failure to take action to comply with a requirement made a year ago to protect residents from the risk of burns from heaters gives cause for concern about the health and safety of residents. A dip in the floor on one of the corridors, which is difficult to see due to being covered in carpet, needs attention to reduce the risk of falls. Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 7 Improvements to the recruitment procedure are required to ensure that all required checks are made in all cases, and that a full employment history is obtained to ensure that residents’ are properly protected. 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. Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, Std 6 was not inspected, as intermediate care is not provided. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process provides assurances that the needs of residents entering the home can be met. EVIDENCE: Records for three residents’ whose care files were reviewed confirmed that there is a process in place to ascertain if their needs can be met prior to admission. Records show that an assessment of prospective residents’ needs is carried out which includes consideration of their personal care needs and any mental health or nursing needs. Questionnaires received from four residents all said they had had enough information to make a decision about moving in to the home. A resident spoken with during the inspection said that her daughter had gathered all of the information about the home, which she had discussed with her before Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 10 admission. The resident was happy that her needs were being met, she hadn’t known what to expect but was “pleasantly surprised”. Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. 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. Residents receive a good standard of personal and nursing care with appropriate access to health care services. EVIDENCE: Comments received in four questionnaires from residents identify that two feel that they always get the care and support and the medical support that they need while two say they usually do. A relative spoken with was very happy with the level of care and support provided. Care plans were in place to guide staff in the actions required to meet the needs of residents. A sample check of the plans confirmed that these include the individual needs and preferences of residents’. For example one care plan reviewed included the time the resident likes to go to bed and get up in the morning, the number of pillows that they like, the light they like left on and that they prefer a duvet to a blanket. All of these are important in assuring Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 12 the comfort of the resident. For those residents who need assistance with personal care, the care plans identified what they can do independently and what assistance is needed which avoids staff taking away residents independence unnecessarily. Care records demonstrated that assessments are in place to identify health care risks such as nutritional risks and the risk of pressure sores. Where these are identified, care plans are in place, which detail the care to be provided to reduce the risk. For example pressure relieving mattresses and cushions for residents identified as being at risk of pressure sores, and a sample check confirmed that these are in place demonstrating that residents are receiving care as planned. Good relationships appear to have been established with the local General Practitioner and the Older Peoples Specialist Nurse team who visit regularly to discuss and advise on any concerns about residents’ health. Health care professionals such as the Dietician, Speech and Language therapist, Tissue viability Nurse and Community Psychiatric Nurse are accessed as appropriate in order to meet residents’ healthcare needs. The majority of care plans sample checked confirmed that they are reviewed regularly and updated as residents’ needs change. However in one case although there were detailed records of changes to the care for a resident with a percutaneous gastronomy tube (PEG) fitted alongside the care plan, the plan itself had not been updated, running the risk that a new member of staff or one that had been away may not have picked up on the changes and provided appropriate care. The Registered Manager confirmed on the morning following the inspection that this plan had been updated. A sample check of medication and observations of medication administration identified that there are systems in place to ensure that residents prescribed medication is available and safely administered. A requirement was made at the last inspection about the accuracy of records of controlled drugs. A sample of the drugs held was checked against the record and was found to be accurate. Stocks were not excessive but there was sufficient to enable residents to receive prescribed pain relief. The Registered Manager has implemented monthly drug audits in order that any errors or poor practices can be identified and addressed with individual staff if necessary to minimise the risk to residents. Observations of staff interactions confirmed that they speak to and treat residents with respect. Two residents spoken with confirmed that they had no concerns about the way they were treated by staff. A staff member was observed to be taking care to cover a resident with a blanket while hoisting them from a wheelchair to a chair in order to protect their dignity. Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 13 Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 14 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. This judgement has been made using available evidence including a visit to this service. Residents’ preferences in relation daily to their routines are respected, they are happy with the meals and their visitors are welcomed and encouraged to visit enhancing their lives. EVIDENCE: The majority of residents’ are very dependent on staff for assistance with their daily routines, such as getting up and going to bed and many are unable to mobilise independently. Residents’ preferences appear to be respected and their preferred times for getting up and going to bed are recorded in their care plans. A resident confirmed they were happy with the support they get and through discussion about the daily routines a member of staff demonstrated an awareness of individual’s preferred routines. There were no specific activities on the day of inspection, however there is an activity organiser who carries out activities with residents usually five afternoons a week. Records are kept to confirm this and of what activities residents’ have taken part in and when. The activities consist of group Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 15 activities and one to one activities. Staff also advised that outside entertainers visit to provide additional stimulation. Staff said that visiting arrangements are flexible, which was confirmed by a relative who was visiting. The relative said that they are made welcome by staff who will arrange for the resident to be assisted to their room if preferred and that they can visit as often as they wish at times which fit in with their working patterns. There was evidence that residents’ are encouraged and supported to exercise choice and control over their lives. Care records show that where possible residents are involved in their care planning. Discussion with staff and observations during the inspection identified that staff and health professionals were working closely and sensitively with a resident to ensure that they were aware of their health needs and were supported to make decisions about their care. Questionnaires received from residents’ indicated that most were generally happy with the food; one said they weren’t but as the response was anonymous it wasn’t possible to identify the person to gather more information. However residents’ appeared to be enjoying their lunch time meal and those spoken with were happy with the food provided. Lunch is a three course meal and staff said that residents’ always particularly enjoy the soup which is always home made. Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 16 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, 17, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives awareness of the complaint procedures and staff awareness of their responsibilities for safeguarding people in their care provides residents’ with good protection. EVIDENCE: The Commission for Social Care Inspection have received no complaints since the last inspection. The registered manager advised that no complaints had been received directly by the home, though discussion with a relative and responses confirm that people feel able to raise any concerns if they arose. The protection of residents’ legal rights was discussed in relation to a resident with dementia who has a pressure mat in their room, which alerts staff with an alarm if the resident gets out of bed. Discussion with the registered manager identified that this had been put in place to protect the resident and other residents. However advice was given to ensure that, in all cases there is evidence that the resident’s capacity to consent has been assessed as required by the Mental Capacity Act 2005. There should also be agreement between all of those involved with the resident including relatives and relevant health professionals that it is in the best interests of the resident and that the least restrictive option is used. Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 17 Discussion with the registered manager and staff confirmed that they are aware of their responsibilities in relation to protecting the vulnerable people in their care. A resident spoken with said she felt safe in the home. Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 18 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, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have a clean and comfortable home to live in. EVIDENCE: A sample check of residents’ bedrooms and shared rooms was carried out and all areas were clean and tidy. Questionnaires from residents’ and discussion with them confirmed that the home is always fresh and clean. Residents’ bedrooms were comfortably furnished and contained personal possessions including family pictures creating a homely environment for them. There is also a room, which has been set aside for use by residents and their relatives if they prefer to have a private visit without using their bedroom. The room is furnished like many domestic lounges and provides a comfortable and relaxed environment for family visits and multi-disciplinary meetings. Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 19 Since the last inspection infection control procedures have been reviewed and training provided in infection control, reducing the risk to residents. Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 20 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 good. This judgement has been made using available evidence including a visit to this service. Staffing arrangements meet the needs of residents, however the recruitment procedure needs to be reviewed to ensure the risk to residents is minimised. EVIDENCE: Residents, staff and a relative spoken with were satisfied that there are enough staff to meet the needs of residents. Staff were observed to be responsive to residents’ needs during the inspection and presented as being caring and committed. There is a good staffing structure within the home and staff are aware of their responsibilities for providing and monitoring the standard of care. A relative and a resident described the staff as very good and caring. The training programme was discussed with the training manager who plans and organises training for the organisations two homes. This demonstrated that a range of training is provided appropriate to the needs of residents and that further training is planned to address any shortfalls. Discussion with two staff members confirmed that appropriate training is provided to enable them to meet the needs of residents. Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 21 The adequacy of the recruitment process in protecting residents was reviewed through a sample check of staff files. This identified the need to review the process in line with the regulations. For example the application form only requests details of the last three employers, whereas the regulations require a full employment history to be obtained. In most cases staff are not employed unless a satisfactory criminal record bureau clearance has been obtained by the organisation, however in one exceptional case, where other satisfactory information had been obtained including a copy of a recent criminal record bureau check by the previous employer a staff member had started work. Advice was given that as a minimum a check against the protection of vulnerable adults register must be made and there must also be evidence of the supervision arrangements in place to protect residents. Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 22 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 good. This judgement has been made using available evidence including a visit to this service. Management and oversight of residents care is good, however the health and safety of residents is not fully protected in relation to the risk of burns. EVIDENCE: The registered manager is an experienced manager and a qualified nurse and is currently undertaking a diploma in management. The home appears to be well organised and managed and staff said they felt supported by the manager in their roles. Quality assurance systems are in place and the last quality review was carried out in October 2006. This involved gathering views from relatives, residents Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 23 and staff about the quality of care provided. The results identified that the majority of residents were satisfied with their care. Some of the suggestions for improvement indicated that residents were encouraged and supported in giving suggestions for improvement. There was evidence that action had been taken to address the issues raised. The registered manager advised that all current residents have a relative or a solicitor who assists them as necessary in managing their financial affairs and that no money is held on their behalf. Payment for things such as hairdressing and chiropody are dealt with through invoicing to reduce the risks associated with holding cash on behalf of residents. Staff training records show that they receive training in safe working practices and observations during inspection identified that the registered manager monitors staff practices. For example while the majority of staff were following correct and safe procedures and ensuring that footplates were used on wheelchairs to reduce the risk of injury, a staff member had to be reminded of the need. A risk was also identified with a dip in the floor on the nursing unit, the registered manager confirmed that she had highlighted this with the owners, however currently none of the residents in that area are able to mobilise independently. It is however of concern that there is little evidence of any action being taken to comply with a requirement to protect residents’ from risks associated with the high surface temperature of heaters. At the time of the inspection the weather was very warm and the temperature of the heaters had been reduced, reducing the risk to residents. However the risk is likely to increase again, dependent on the outside temperature. The registered manager advised that she is pursuing this issue with the owners and would carry out risk assessments to ascertain the risks to individual residents. Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 2 18 3 3 X X X X 3 1 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 X 3 X 3 X X 2 Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 25 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 OP25 OP38 Regulation 13 (4) (a) Requirement Action must be taken to protect service users from the risk of burns from heaters and radiators without low surface temperature covers. (This requirement is outstanding from the last inspection with a timescale of compliance of 05/06/06) Prior to employing a new member of staff, information obtained must include a full employment history and criminal record bureau clearances. In the exceptional circumstance where it is necessary to employ someone prior to receipt of the criminal record bureau clearance, there must be evidence that all other checks including the protection of vulnerable adults register have been made and of the supervision arrangements to protect residents’. Timescale for action 15/06/07 2. OP27 19 21/05/07 Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 26 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 OP17 Good Practice Recommendations Where equipment such as a pressure mat is used which places a potential restriction on a resident’s freedom of movement there should be evidence that their legal rights have been protected with reference to the Mental Capacity Act 2005. Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Polebrook Nursing & Residential Home DS0000012633.V334429.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!