Inspection on 17/10/05 for Polefield Nursing Home

This inspection was carried out on 17th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Polefield Nursing Home 06/12/06

Polefield Nursing Home 23/02/06

Polefield Nursing Home 17/02/05

Polefield Nursing Home 01/09/04

Polefield Nursing Home 04/03/04

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 Polefield Nursing Home 77 Polefield Road Blackley Manchester M9 7EN Lead Inspector Kath Oldham Unannounced Inspection 17th October 2005 08:10 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 Polefield Nursing Home DS0000021655.V253499.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. Polefield Nursing Home DS0000021655.V253499.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Polefield Nursing Home Address 77 Polefield Road Blackley Manchester M9 7EN 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) 0161 795 4102 0161 740 4903 Rosewood Care Services Limited Ms Kay Rooney Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (38), Physical disability (2) of places Polefield Nursing Home DS0000021655.V253499.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users requiring nursing care shall be 37 and the maximum number of service users requiring personal care only shall be 3. All service users are aged 60 years and over except two named service users requiring care by reason of physical disability. Registration is subject to compliance with the minimum nursing staffing levels indicated in the Notice previously served in accordance with Section 25 (3) of the Registered Homes Act 1984 issued on 20 December 2000. 17th February 2005 Date of last inspection Brief Description of the Service: Polefield Nursing Home is registered to provide accommodation with nursing care for a maximum of 40 older people. The home is able to accommodate 37 older people assessed as requiring nursing care in addition to 3 older people assessed as requiring personal care only. Rosewood Care Services Limited owned the premises, along with an additional home in the Liverpool area. Mr John Sleigh is the Responsible Individual on behalf of the organisation. Mrs Kay Rooney is the Registered Manager. The home is situated in a residential area in the Blackley district in the North of the City of Manchester. The home is well served by good public transport links and within easy reach of Manchester, Rochdale and Oldham Centres. The home is close to local facilities, shops, Boggart Hole Clough Park and other community social, cultural and recreational facilities. The home was first registered with the Commission for Social Care Inspection (CSCI), on 30th July 2002. The home is a large; purpose built building, which provides accommodation on two floors for up to 40 service users. The home’s second floor offered office accommodation and storage. The home has off road parking for approximately 10 - 12 vehicles. The main entrance to the home has low ramp access and was accessible to wheelchair users. A passenger lift provides access to all levels of the home. The home provides accommodation within 24 single and 8 double bedrooms. The ground and first floors had communal lounge and dining facilities. The first floor has a large balcony area that overlooks the well-maintained gardens. The home and its garden areas are accessible to residents. Polefield Nursing Home DS0000021655.V253499.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the day, starting shortly after 8.00am on 17th October 2005. Time was spent in conversation with residents and their friends and visitors. A partial inspection of the building was undertaken in addition to observing staff practice and routines. The registered manager was on holiday so time was spent with the care manager and the Responsible Individual. Examination of a sample of documents that should be maintained for the purpose of regulation was undertaken. Comment cards were left at the home to give out to residents, visitors and relatives. Their comments are included in the report. What the service does well: What has improved since the last inspection? What they could do better: Some creams prescribed for residents seemed to be being used by others. This practice could put people at risk from infection. There was little written about residents social interest in their care plans, so it was difficult to know whether the staff were aware of and assisted residents to be socially active. The safety of residents could be put at risk by some of the practices seen and recorded in the home. Polefield Nursing Home DS0000021655.V253499.R01.S.doc Version 5.0 Page 6 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. Polefield Nursing Home DS0000021655.V253499.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 Polefield Nursing Home DS0000021655.V253499.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&2 Residents are provided with information to enable them to make a decision as to whether the home can meet their needs. EVIDENCE: The Statement of Purpose and Service User Guide have been amended since the last inspection to ensure that the information contained is up to date. Residents or their representatives were said to have received the Service User Guide. Examination of a sample of care files confirmed that a contract was in place for those residents who are funded by the local authority. The home’s own terms and conditions of residency was not seen in the sample of care files examined. Polefield Nursing Home DS0000021655.V253499.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&9 Systems are in place to ensure, as far as possible, that residents maintain good health. Practices need to be amended in relation to the use of wheelchairs. EVIDENCE: Examination of the care files for recently admitted residents identified a detailed assessment and care plan, which was individualised to the needs and aspirations of the residents. The needs were clearly identified and risk assessments undertaken to identify possible risks to the residents, due to their lifestyle or habits. Daily reports were completed by staff detailing the interactions and health care needs. The reports did not reflect the social care provided to residents. The language used was respectful of the residents. A separate record of doctors’ visits and other health care personnel is maintained within the file, which collectively details all professional visitors. Polefield Nursing Home DS0000021655.V253499.R01.S.doc Version 5.0 Page 10 A number of residents were observed to be sitting for long periods in their wheelchairs as opposed to sitting within a comfortable lounge chair. In addition, staff were observed mobilising residents in wheelchairs without always using footrests. This practice has the potential to put residents at risk. A sample of medication administration records examined detailed medication administered as prescribed by the residents doctor. Not all residents have photographs within their medication records, which would assist in the identification of residents. Specimen signatures were not seen at the inspection but were described by the care manager to be in the treatment room. A record was maintained of the receipt of medication and the quantity received, this detail was recorded and signed on the medication records. The controlled drug register appeared to be appropriately completed with a record maintained of the medication, the dosage and balance of stock signed by two staff. Inspection of one of the bathrooms identified prescribed creams stored in the bathroom and the prescription labels had been removed. Creams should be used for residents that are prescribed to the individual and these should be maintained within their own bedrooms to minimise the risk of other residents using them which could result in cross infection. Notices were observed within the bathroom that gave staff instruction in relation to a residents bathing and hair washing needs. This detail should be recorded in the care plan and not on notices within a bathroom. Polefield Nursing Home DS0000021655.V253499.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 & 15 Residents have a flexible lifestyle in the home and maintain contact with their families and friends. Social activities are lacking. Meals are well presented and were said to be enjoyed by residents. EVIDENCE: An entertainer visits the home on a monthly basis and residents said that they enjoyed specific entertainers. Some activities take place during the day; chair exercises were reported to be enjoyed by residents. A number of residents go out with relatives or friends for walks or visits to their relatives’ homes. It was reported that, in an afternoon, when staff have time they take specific residents for a walk. One resident said they enjoyed sitting in the lounge chatting to other resident and staff, listening to music, watching television or reading. Another resident said they spent their day in their bedroom with their things around them, which they said they preferred. A further resident said she spent the morning in the lounge and in an afternoon went to her room to watch television or read magazines. The records examined did not detail activities undertaken by specific residents. One comment card said that there wasn’t enough to occupy residents. Polefield Nursing Home DS0000021655.V253499.R01.S.doc Version 5.0 Page 12 Residents commented that they can receive visitors at their convenience and they receive them in the lounge or in their rooms. No restrictions were in place to determine when visitors can attend the home. A cycle of menus is available and choices are available at all mealtimes. Staff were observed chatting with residents asking them their meal choices and preferences for the day. A record is sent to the kitchen of residents meal choices for preparation. The cook said that residents could have anything that they want if they did not like or fancy what is on the menu. Residents said they enjoyed the meals and ate what they wanted. A further residents said they had cereal and cooked breakfast everyday. The meals served are traditional meals, which residents said they liked. One residents said there were too many chips on the menu. The meals on the inspection were well presented and were hot. Polefield Nursing Home DS0000021655.V253499.R01.S.doc Version 5.0 Page 13 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 The complaints procedure ensured that all interested parties were aware of how to complain and the process that would be undertaken. EVIDENCE: The complaints record examined did not detail any complaints or comments regarding the quality of care provided. Previous inspections have reported that there were no recorded complaints. The complaints procedure should be used, as part of the home’s development process to monitor the quality of service provided and it should be proactively encouraged to receive comments about service delivery. Comments received at the inspection identified that comments and complaints have been made to the home that had been addressed, however these were not recorded. Polefield Nursing Home DS0000021655.V253499.R01.S.doc Version 5.0 Page 14 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, 23, 24 & 26 Polefield is a well maintained home. However, the safety of residents and staff could be compromised by the wedging open of fire doors. EVIDENCE: The home was clean and free from any offensive odours. A partial inspection of the building identified that bedrooms were personalised by residents and their families with ornaments and furnishings. The bedrooms inspected contained the furniture and furnishings described in the standards. Those seen were decorated in a similar wayand were clean and free from odours. One resident said she had everything that she needed in her bedroom and that she had brought things with her from home to make it more her own. Polefield Nursing Home DS0000021655.V253499.R01.S.doc Version 5.0 Page 15 The registered person said that a couple of bedrooms were going to be redecorated and were having new carpets fitted. The redecoration of the bedrooms is on an ongoing programme. One visitor said that they had asked for their relatives bedroom to be redecorated and this was arranged by the home. A number of bedroom doors were wedged open. One care file examined contained a risk assessment in relation to wedging open the bedroom door. The practice of wedging fire doors open, although undertaken to promote mobility, compromises the health and safety of residents in the event of a fire. The fire policy did not detail actions that must be taken as a consequence of this practice. The fire authority needs to be consulted with in relation to this matter. There are two lounges in the home the smaller being on the ground floor and on the second floor a larger lounge. A variety of chair types are available to assist in residents comfort. A number of residents have brought their own chair from home, which is situated in the lounge. Footstools were available to and staff were observed to support residents to use these. A number of residents took their meals in the lounge. There were no side tables for residents to place their drinks or personal items. Residents were seen placing cups on the arms of chairs or trying to hold hot drinks. The lounges are traditionally arranged with chairs around the perimeter of the room. The gardens can be viewed from the lounge areas. One residents was seen to comment on the view from the lounge window and the wildlife that visits the garden. Inspection of one of the bathrooms identified that a large ceiling tile was missing over the bath and the roof space was accessible. This could result in debris falling into the bathroom when the bath is in use. The registered person said he would arrange for the tile to be replaced. One of the laundry doors had been fitted with a keypad on the door to ensure that residents are not able to gain access. A second door accesses the laundry and residents could potentially go into the laundry from this entrance. The registered person said the home had researched the fitting of a similar type of lock on this door but due to the design of the door this is not possible. Polefield Nursing Home DS0000021655.V253499.R01.S.doc Version 5.0 Page 16 Clinical waste bins stored in the car park were observed to be unlocked and overfull with refuse bags. The registered person said that the home has recently appointed alternative contractors and were awaiting the original contractors to empty the bins. The care manager said that they were ordinarily emptied the day after the inspection. The storage of this waste needs to be organised and the appropriate number of bins obtained to ensure satisfactory arrangements. Polefield Nursing Home DS0000021655.V253499.R01.S.doc Version 5.0 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): EVIDENCE: These standards were not assessed as part of this inspection. Polefield Nursing Home DS0000021655.V253499.R01.S.doc Version 5.0 Page 18 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): 38 The health and safety of residents is, on the whole, promoted. EVIDENCE: A record is maintained of the refrigerator, freezer and hot probe temperatures, which are detailed daily in the kitchen records, in line with environmental health regulations. A kitchen-cleaning schedule is in place, which details the daily cleaning tasks. The cook said she had recently obtained food hygiene training. All the equipment in the kitchen was reported by the cook on duty to be in working order. Polefield Nursing Home DS0000021655.V253499.R01.S.doc Version 5.0 Page 19 Records are maintained of all accidents, incidents and falls, which are filed individually in residents care files in line with Data Protection Regulations. The examination of these records was not possible due to this arrangement. It was reported that the registered manager undertook an accident analysis to identify whether there were any patterns to accidents and to minimise risk to residents. Staff meetings take place, in addition to specific staff meeting within their peer groups. A variety of topics were recorded as having been discussed. The meetings give staff an opportunity to contribute their views on the development of the home. The fire precautions register detailed the weekly checks undertaken to the emergency lighting, extinguishers, fire alarm system and means of escape. Examination of the fire drill training/practice records identified that not all staff had received this training. Staff had signed to say that they had read and understood the fire policies and procedures. Polefield Nursing Home DS0000021655.V253499.R01.S.doc Version 5.0 Page 20 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 2 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 3 X X X 3 3 X 2 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Polefield Nursing Home DS0000021655.V253499.R01.S.doc Version 5.0 Page 21 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 OP2 Regulation 4.8 Requirement The registered person must arrange for each resident to have a terms and conditions of residency with the home. The registered person must ensure that footrests are routinely provided on wheelchairs and these are used when mobilising residents. The registered person must ensure that prescribed creams are only used by the individual who they are prescribed for and all creams and lotions are kept within residents own bedrooms. The registered person must ensure that the residents are consulted about their social and other interests whilst making every effort to facilitate arrangements for these to be continued or recommenced. The registered person must retain evidence to support such actions. (Previous timescale of 17/04/05 not met). Timescale for action 31/12/05 2 OP7 23(2)(c) 30/11/05 3 OP9 13(2) 30/11/05 4 OP12 12 31/12/05 Polefield Nursing Home DS0000021655.V253499.R01.S.doc Version 5.0 Page 22 5 OP26 13(4)(a) (c) 6 7 OP26 OP38 16(2)(k) 23(4) 8 OP38 23(4) The laundry was accessible and could be dangerous to confused residents. The responsible individual must take reasonable precautions to protect the residents from such harm e.g., by fitting a digital door lock to the laundry door situated on the ground floor corridor. Interim safety measures must be taken as discussed at the inspection on 17/02/05. (Previous timescale of 17/04/05 not met in full). The registered person must make suitable arrangements for the disposal of clinical waste. The registered person must arrange for all staff to undertake fire drill training/practice at intervals of not more than six monthly. The registered person must cease the routine and practice of wedging open fire doors and consult with the fire officer regarding practices within the home. 31/12/05 31/10/05 31/10/05 31/10/05 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 3 Refer to Standard OP7 OP7 OP9 Good Practice Recommendations The registered person should ensure that the care plans daily reports include the social care needs of residents The registered person should discontinue the routine of displaying notices within the bathroom informing staff of residents bathing needs. The registered person should arrange for individual photographs to be taken of all residents, which are placed with the medication administration records. Polefield Nursing Home DS0000021655.V253499.R01.S.doc Version 5.0 Page 23 4 OP12 5 6 OP16 OP31 The registered person should ensure that the residents are regularly involved in an appropriate forum whereby they are able to influence the conduct and management of the home. Records should be maintained of such involvement. The registered person should develop the complaints procedure to ensure that comments and complaints are routinely recorded in the complaints record. The registered person should arrange for the manager to complete a course of study that will enable her to achieve the registered manager’s award. Polefield Nursing Home DS0000021655.V253499.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Polefield Nursing Home DS0000021655.V253499.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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