Inspection on 18/07/05 for Polesworth Group 32 Station Road

This inspection was carried out on 18th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Polesworth Group 32 Station Road 26/04/07

Polesworth Group 32 Station Road 22/12/05

Polesworth Group 32 Station Road 26/02/05

Polesworth Group 32 Station Road 23/09/04

Polesworth Group 32 Station Road 11/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

1a White Ladies Close

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

CARE HOME ADULTS 18-65 Polesworth Group - 32 Station Road 32 & 32a Station Road Polesworth Staffordshire B78 1BQ Lead Inspector Catherine Mundy Unannounced 18 July 2005 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Polesworth Group - 32 Station Road E53 S4283 Polesworth Group 32 Station Road V239917 180705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Polesworth Group - 32 Station Road Address 32 & 32a Station Road Polesworth Staffordshire B78 1BQ 01827 896124 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Polesworth Group Homes Limited Ms Susan Black CRH Care home 8 Category(ies) of LD Learning Disability (8) registration, with number PD Physical Disability (1) of places Polesworth Group - 32 Station Road E53 S4283 Polesworth Group 32 Station Road V239917 180705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for eight (8) service users in the category of Learning Disability, of which one (1) may also have a Physical Disability. Date imposed 29 April 2005. Date of last inspection 26 February 2005 Brief Description of the Service: Polesworth Group Homes was established as a limited company in June 1991, with the aim of providing accommodation and support for adults with learning disabilities. 32 Station Road is a care home for eight residents and it is situated in Polesworth near Tamworth. The property is a converted nurses’ home on two floors and is unidentifiable as a care home, blending into surrounding residential properties. The home offers six single and one shared bedrooms. On the ground floor there are three bedrooms, a dining room, a large lounge and a conservatory, the kitchen, a utility room, a staff office and sleeping room, a shower room and toilet. Upstairs there are four bedrooms, a bathroom and a toilet. The premises are well maintained and decorated, the furniture and fittings are of good quality. Externally to the rear there is a garden with a lawn, flowers and shrubs and the patio area. The craft room, which is a resource centre for all service users in Polesworth Group Homes, and the registered managers office, is also situated at the side of the property. The front of the home provides car parking spaces. The home is staffed 24 hours a day and cares for residents with medium to high levels of need. Some residents have high healthcare needs as well as learning disabilities. There is a plan to reduce the number of residents admitted to the home when vacancies occur. Polesworth Group - 32 Station Road E53 S4283 Polesworth Group 32 Station Road V239917 180705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 18th July 2005 between the hours of 2 pm and 5.30 pm. During this time the inspector had the opportunity to meet with the residents and one residents relative, observe the interactions between the residents, staff and their environment, tour the home and examine documents relating to the residents and the management of the home. Three staff members were involved in the inspection process. What the service does well: What has improved since the last inspection? All of the three requirements made during the last inspection have been addressed. To maintain the residents privacy a lock has been fitted to the first floor bathroom and a privacy screen has been provided to the shared bedroom. The procedures for the administration of medication have been reviewed and now reflect good practice. It is pleasing to note that requirements and recommendations made at inspections of other premises managed by the organisation have been shared and implemented within the home. The inspector is advised that other good practice ideas are also shared within the organisation. Polesworth Group - 32 Station Road E53 S4283 Polesworth Group 32 Station Road V239917 180705 Stage 4.doc Version 1.40 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. Polesworth Group - 32 Station Road E53 S4283 Polesworth Group 32 Station Road V239917 180705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Polesworth Group - 32 Station Road E53 S4283 Polesworth Group 32 Station Road V239917 180705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 The residents are provided with sufficient information which details the services provided in the home, this information would be provided to prospective residents to enable them to make an informed decision as to whether to accept a placement in the home. EVIDENCE: The home has a Statement of Purpose which details the services provided in the home. This had recently been reviewed. The staff confirmed that this document would be made available to prospective residents prior to making a decision to move into the home. Each of the residents have been issued with a Service Users Guide to the home and a contract detailing terms and conditions of residency. The residents hold these documents, they were not examined during this inspection, as it has been noted at previous inspections that these documents are acceptable. There have been no new admissions to the home since the time of the last inspection and there are no vacancies within the home. The remaining standards within this section were met at the previous inspection and were therefore not assessed on this occasion. Polesworth Group - 32 Station Road E53 S4283 Polesworth Group 32 Station Road V239917 180705 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 The care planning system in place is good, providing the staff with sufficient information to enable them to meet the residents identified needs. The residents are provided with opportunities, supported by the use of appropriate communication aids, to make decisions regarding their everyday lives. EVIDENCE: The residents are provided with a plan of care which details the actions to be taken by the home in order to meet their identified needs and wishes. Risk assessments have been completed and risk management strategies have been developed to address the risks identified. Both the care plan and risk assessments are subject to regular review. The residents are supported to make decisions regarding their every day lives, including holiday destinations, activities, daily routine, meals and personal appearance. The residents confirmed that the decisions made are respected by the staff. The staff support the decision making process using a variety of communication aids as appropriate to the needs of the residents. These include the use of visual prompts, symbols, sign language and pictorial aids. The use of these aids was observed during this inspection. Polesworth Group - 32 Station Road E53 S4283 Polesworth Group 32 Station Road V239917 180705 Stage 4.doc Version 1.40 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 14 and 17 The residents are supported to participate in valued and fulfilling activities which they enjoy. The residents enjoy the meals provided by the home. The home offers a varied diet, which reflects the residents choice and caters for special dietary needs. EVIDENCE: The residents are supported to take part in valued and fulfilling activities, during the day, in the evenings and at weekends. Three of the residents attend a structured day placement on week days, the other residents are supported by the home to access activities of their choice. This includes craft sessions and college courses. The home has employed a member of staff specifically to facilitate these activities. Leisure opportunities available in the evenings and at weekends include bingo, going to the pub, having meals out, visiting family and friends, listening to music, watching television, and relaxing at home. The residents confirmed that they enjoy taking part in the activities provided. The residents confirmed that they enjoyed the meals that are provided. It is advised that each evening the residents choose the meal for the next day. The residents confirmed that an alternative meal is provided if requested. Polesworth Group - 32 Station Road E53 S4283 Polesworth Group 32 Station Road V239917 180705 Stage 4.doc Version 1.40 Page 11 Ample food stocks were available to support this. The residents assist with food shopping, providing another opportunity for the residents to choose the meals provided. During the inspection the residents were consulted as to how they would like their evening meal to be served, condiments were also available. One resident is supported by a dietician, specialist aids are available to support other residents to maintain independence at meals times. Polesworth Group - 32 Station Road E53 S4283 Polesworth Group 32 Station Road V239917 180705 Stage 4.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 The residents personal care needs are met in a way which reflects their personal choice, and promotes their privacy, dignity and independence. The staff have a good understanding of the residents health care needs, and are supported by the relevant health care professional to enable them to meet residents needs effectively. The systems in place for the management of the residents medication are good, clear guidance is in place to ensure that the residents medication needs are met. EVIDENCE: The residents preferred daily routines are clearly detailed in their individual plans of care. These reflected that the residents privacy, dignity and independence are respected. The interactions observed between the staff and residents confirmed this. The plans of care also detail the residents health care needs. Records are made of any contact with healthcare professionals and any incident, which may affect the residents health. The outcome for the resident is also recorded. Some of the residents have complex health care needs, the staff were able to demonstrate that they had the skills and knowledge to enable them to meet these residents needs effectively. Polesworth Group - 32 Station Road E53 S4283 Polesworth Group 32 Station Road V239917 180705 Stage 4.doc Version 1.40 Page 13 The staff demonstrated an understanding of the actions that should be taken to prevent deterioration in the residents health and of the actions that they should take in the event of an emergency. The home is supported by the relevant healthcare professional in order to meet the needs identified. The needs of the residents are such that the home maintains responsibility for the management of the residents medication. The procedures in place for storage, administration and recording reflect good practice. In order to maintain a consistent approach to the administration of ‘ as required’ medications, administration protocols have been devised. The requirement made at the last inspection to dispense and administer each residents medication individually has been addressed. The staff discussed how their practice had changed since this requirement was made. This was observed. Written administration procedures are also available. This reduces the risk of a resident receiving medication prescribed for another. It is recommended that, when additional administration record sheets are used, the home numbers the pages of the medications administration record. This will reduce the risk of individual pages being misplaced which may result in medication errors. Polesworth Group - 32 Station Road E53 S4283 Polesworth Group 32 Station Road V239917 180705 Stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The home has a satisfactory complaints procedure in place, the residents are confident that the concerns they raise will be listened to and acted upon. The homes policies and procedures protect the Service Users from abuse. EVIDENCE: The home has an acceptable complaints procedure in place. This details the actions to be taken by the staff, manager and organisation in order to resolve any complaints made or concerns raised. The staff also demonstrated through discussions that, in the event of a complaint being made, appropriate action would be taken. It is advised that there have been no complaints made to the home since the last inspection. This was not verified, as the complaints log could not be located during the inspection. It has since been advised that this log is retained in the homes quality assurance file, this will be examined during the next inspection of this home. A relative of one resident confirmed that she is happy with the care that is provided by the home and had not had cause to make a complaint. The comments made by this relative were extremely complimentary of the service provided in the home. The complaints procedure is also provided in a format that is more accessible to the residents, this is displayed prominently within the home. The residents confirmed that should they wish to make a complaint or raise a concern they would feel confident in discussing this with their key worker or the other staff on duty. The residents confirmed that if the concern was not addressed they would be able to raise the issue with the homes manager. The organisation also facilitates regular house meetings, the residents and staff confirmed that these also provide a forum for the residents to raise concerns. Polesworth Group - 32 Station Road E53 S4283 Polesworth Group 32 Station Road V239917 180705 Stage 4.doc Version 1.40 Page 15 These are not attended by the homes manager or the staff. The minutes relating to these meetings are retained by the organisations representative. It is advised that this is to reassure the residents that the content of the meetings is confidential. The organisations representative advised that any issues raised are addressed appropriately. The home has an adult protection and whistle blowing policy in place. These were available in the home and are provided as part of the staff handbook. The financial records relating to one resident were examined. These indicated that the residents monies are handled appropriately by the home. Polesworth Group - 32 Station Road E53 S4283 Polesworth Group 32 Station Road V239917 180705 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30 Whilst the standard of the environment is good providing a comfortable and homely place to live, further action is required in order to ensure the safety of the residents and staff. EVIDENCE: The home is comfortable, clean and homely. Décor and furnishings are of good quality and well maintained. The requirements made at the time of the last inspection, to provide a privacy screen to the shared bedroom and provide a lock to the bathroom door have been addressed. Laundry facilities are appropriate to the needs of the home. The staff confirmed that the procedures in place to attend to the residents laundry are acceptable. Soiled items can be washed at appropriate temperatures and sluicing facilities are also available. Cleaning materials are stored in a lockable cupboard, it is disappointing to note that this was not locked, this may have placed the residents at risk. The staff rectified this during the inspection. It is also disappointing to note that the laundry door was propped open. This would affect the safety of the residents and staff in the event of a fire. Polesworth Group - 32 Station Road E53 S4283 Polesworth Group 32 Station Road V239917 180705 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: The standards within this section were not inspected on this occasion. Polesworth Group - 32 Station Road E53 S4283 Polesworth Group 32 Station Road V239917 180705 Stage 4.doc Version 1.40 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Although the home takes some action to promote the health and safety of the residents and staff, further action is required to ensure that their safety is not compromised. EVIDENCE: The arrangements for the storage and preparation of foods are good. The home monitors the temperatures of the fridge and freezer on a daily basis. The temperature of the meals to be served is also checked and recorded. There is evidence of stock rotation within the fridge and freezer. These practices reduce the risk of ill health to the residents. It is advised that water outlets, to which the residents have access are fitted with temperature regulators, these reduce the risk of scalding. To ensure that these regulators are in working order the water temperatures are tested each week, however records relating to this could not be located during the inspection. Polesworth Group - 32 Station Road E53 S4283 Polesworth Group 32 Station Road V239917 180705 Stage 4.doc Version 1.40 Page 19 The home monitors the fire safety equipment provided. Emergency lights and fire alarms are tested each month by an external contractor, fire alarms are also tested each week by the home. Fire fighting equipment is serviced annually. The doors, which are required to be kept open have been fitted with door closing devices that are activated when the fire alarm is sounded. This is with the exception of the door to the laundry which had been propped open with a door wedge. In the event of a fire this practice will place the residents and staff at risk. Polesworth Group - 32 Station Road E53 S4283 Polesworth Group 32 Station Road V239917 180705 Stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 2 Standard No 11 12 13 14 15 16 17 x 3 x 3 x x 3 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Polesworth Group - 32 Station Road Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x E53 S4283 Polesworth Group 32 Station Road V239917 180705 Stage 4.doc Version 1.40 Page 21 No 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. 2. 3. 4. Standard 30, 42 24, 42 Regulation 13(4)(a ) 13(4)(a ) 23(4) (c ) (i) Requirement Timescale for action 18/7/05 Cleaning materials must be stored securely. The door to the laundry must not 18/7/05 be propped open. - 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 20 Good Practice Recommendations Additional pages that are added to the medication administration records should be numbered. Polesworth Group - 32 Station Road E53 S4283 Polesworth Group 32 Station Road V239917 180705 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB 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 Polesworth Group - 32 Station Road E53 S4283 Polesworth Group 32 Station Road V239917 180705 Stage 4.doc Version 1.40 Page 23 - 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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