Inspection on 26/04/07 for Polesworth Group 32 Station Road

This inspection was carried out on 26th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 22/12/05

Polesworth Group 32 Station Road 18/07/05

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 Sheila Briddick Key Unannounced Inspection 26th April 2007 09:30 Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 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 Polesworth Group 32 Station Road DS0000004283.V336803.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 Adults 18-65. 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. Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Polesworth Group 32 Station Road Address 32 & 32a Station Road Polesworth Staffordshire B78 1BQ 01827 896939 01827 331840 stationroad@polesworthgh.wanadoo.co.uk 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) Polesworth Group Homes Limited Ms Susan Black Care Home 8 Category(ies) of Learning disability (8), Physical disability (1) registration, with number of places Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 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. 22nd December 2005 Date of last inspection 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. The current scale of charging is £513- £969. Additional costs that have to be met by people include toiletries, outings, holiday spending money and hairdressing. Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Prior to the inspection visit the manager had forwarded to the Commission a pre-inspection questionnaire, a staffing rota, training information and menu records for the home. Service user and relative questionnaires were sent out and eight service user and four relatives responses where returned. All prerequested documentation returned was examined as part of the inspection process and the evaluation included in this report. The visit took place on Thursday, April 26th 2007 at 9.30 am; this was arranged with the manager on April 25, 2007. The inspection visit finished at 3.30pm. April 26, 2007. The inspection involved: • • • Discussions with people who use the service and staff on duty at the time. Observation of working practices and of the interaction between people and staff members. Two people were identified for close examination by reading their, care plans, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’ where evidence is matched to outcomes for people. A tour of the environment was undertaken, and home records were sampled, including staff training, health and safety, and quality assurance records. Finally, feedback took place with the manager about the inspection findings. • • I would like to thank the people who use the service and staff for their hospitality and co-operation during the inspection visits. What the service does well: The service continues to provide a warm, friendly home of exceptionally high environmental standards, where people with varying needs and skills live together and are cared for in a very positive way by a dedicated, motivated and well-organised staff team. Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 6 All information gathered during the visit demonstrated that the ethos of the home is to achieve positive outcomes for people, which includes ensuring that the facilities, staffing and lifestyle meets the diverse needs of the people living there. Central to the home’s aims and objectives is the promotion of people’s right to live an ordinary and meaningful life both in the home and in the community in which they live. Mealtimes are flexible and relaxed, staff are patient and helpful and allow people the time they need to finish their meal comfortably. Specific dietary needs are provided for to a high standard. During the visit people were asked what they liked best about living in the home and they made the following comments. • • • I like the staff. The cook works hard and deserves a rise. Rose takes me shopping and Im happy. The staff are nice and I like it here. Comment cards completed by relatives included separate comments all of which were positive about the service provision. For example; • • • I think the home does a wonderful job, the home is always spotless. The staff are jolly and helpful, I would not think there is a better place for my relative to be. My daughter is very happy and my husband and I are very happy to know she is well looked after. What has improved since the last inspection? What they could do better: High standards continue to be maintained all round and no requirements were made at this inspection. The manager is keen however for staff working in the home to access pressure sore awareness training and intends to discuss this with the designated training coordinator for the service. Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 7 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. Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. New people coming to live in this home can be confident that their needs will be assessed and reviewed in a manner that is relevant to them, and that they will be fully involved in the process. EVIDENCE: Since the last inspection there has been two new people coming to live in the home and these records were looked at. Care plans were up-to-date and demonstrated that assessed needs were being reviewed regularly as people settled into their new environment. There was documentation to show that the relevant placing authority had been involved in the admission process and specialist services also. For example, psychologists, speech language services and continence advisers, had been included in the assessment and planning of the care plan, which was based on the care management assessment. Service level agreements and contracts were in place on each care plan. One person’s admission had been an emergency admission and the home is to be commended for the management of this emergency placement. There was evidence to suggest that within the short timescale for the admission to take Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 10 place the service had worked closely with social work teams, community nurses, district nurses and the family in ensuring all necessary equipment, including a specialist bed and mattress were in place prior to the person coming into the home. A family member visiting at the time of the inspection whose care plan was looked at told us they had been made very welcome and been able to visit their relative whenever they wished to be sure that they were settling into the home. They said, We cant fault anything, and our relative is happy and staff will do anything for her. A person spoken with, who had recently come to live in the home, told us that they were still able to visit their family home as often as they wished. They said that this was usually at weekends and although they had brought many of their possessions with them they still preferred to have some remain in their family home. Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 6, 7 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people living in this home can be confident that their needs and wishes will be met and that they will be fully consulted and kept informed concerning the ways in which this is done. EVIDENCE: The care plans for two people were looked at and this included their risk assessment information and review forms. Each care plan looked at had clear written guidelines for staff to follow to meet specific needs, this included keeping people safe from harm in their environment and activities, communication, mobility support and significant behaviours. Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 12 The daily routines for each service user were very detailed and included the specific times preferred for their daily activities, for example times for getting up and times for going to bed. Staff spoken with felt that care plans gave them satisfactory information to meet needs and supported their role in the care home. The staff team have opportunity to discuss care planning and working with people at their team meetings and this is supporting consistency of care practices with people. The key worker for one of the people whose care was being looked at was very knowledgeable about the specific care needs of the person they were supporting and fully aware of the aims and objectives of the care plan. They told us about the work they were doing with speech and language services to enable the person to communicate through the aid of a talking album, (Liberator Speech Machine). They told us how they had worked with district nurses to treat the pressure sore that the person had when they were admitted to the home. They said that although they had no specific training in pressure sore care the tissue viability nurses gave them clear instruction, which was recorded on the care plan for them to follow. The key worker was particularly pleased with the progress the service user was making and the impact this was having on their lifestyle, for example, as the pressure sore was now healed the person was sitting in a wheelchair for two hours each day which meant they were able to go out into the community for short periods. Risks to people are assessed and strategies put in place to keep people from harm. There is evidence to suggest that people are involved in their risk assessment strategies. Psychology services are also included in the decisionmaking process regarding risk management and in agreeing guidelines for staff to meet identified needs. People said they had opportunity to talk with the provider about life in the home. They said they are asked what choices of food they would like and said that if they were not happy they knew whom they home could talk to. Throughout the visit people living in the home appeared relaxed and comfortable with the people who were supporting them. They were able to move around freely and be involved in all the activities that were happening. Staff involved people in all decisions being made, for example planning the mornings activities, agreeing lunchtime and times to get ready for the evening activity. Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people living in this home have excellent support to live ordinary and meaningful lives and to participate in, and contribute, to the community in which they live. EVIDENCE: The activity diaries and lifestyle records of the three people whose care was being looked at were examined. This determined that activities for people are varied and regular and support a meaningful lifestyle. People spoke about the activities they enjoyed and this included their holidays away from the home, attending their day centre, shopping, and eating out. On the day of the visit people were very excited about a trip out of that evening to see the greyhound racing. They had done this before and were looking forward to the meal and had agreed how they would spend their money. Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 14 People who use the service told is that going out was the best thing about living in his home. They told us that they went out every day and on the day of the visit people were either attending their day centre, going to work, shopping locally and going out for coffee or lunch. People told us that they use local services, such as the hairdresser, dentist and optician. One person said I get out every day, and go shopping for clothes with my key worker. We found that lifestyle within the home is comfortable, relaxed with the opportunity to be involved if you wish. Activities within the home include aromatherapy, watching videos and listening to music. The manager said that work on life storybooks is to continue and these will be recorded with photographs and people own words in specially bound booklets. One person is having to spend some time having bed rest during the day and we observed that if it is the persons wish their bedroom door is left open so that they can still see what is going on in the home. They appeared to enjoy people coming into their room to visit them, and this included other people who were using the service. There was a warm and friendly atmosphere within the house and visiting relatives said that this is one of the best things about the service saying that there was always a good interaction between the service users and staff. People were complimentary about the food provision in the home and said that this was one of the things they liked best about living there. There is good evidence on care plans that the specific dietary needs of individuals has been identified and appropriate specialist support, i.e., dieticians and speech and language therapists, sought. Staff spoken with were knowledgeable about the of specialist dietary needs of individuals and this included a good understanding of working to the specific guidelines on care plans for people with swallowing difficulties or required thickening food agents in their drinks and the importance of recording all food and food intake. Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people living in this home can be sure that the health and personal care they receive is based on their individual needs and that the principles of respect, dignity and privacy are put into practice when care is offered to them . EVIDENCE: Examination of care plans and discussion with staff found that the personal care needs of the individuals continues to be offered to them according to their needs and that the staff have a good knowledge of how people wish their care to be supported. Care practices observed during the visit were sensitive and respectful and people appeared satisfied with their care received. They said “Staff look after me nicely and they talk to me nicely too” and “The staff are nice and I like it here”. There is significant evidence that the advice has been sought when care planning from continence advice specialists, learning disability nurses, Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 16 physiotherapists and behavioural therapists. Staff spoken with said the advice and guidance from specialist played a significant part in enabling them to meet individuals specific needs appropriately and safely. They spoke of working closely with district nurses regarding the treatment of a pressure sores and how the nurses had given them clear instruction to follow. The manager and staff however felt that it would be beneficial for all staff to have training in tissue viability awareness as part of good practice development. All records relating to health looked at were in good order and welldocumented with evidence that monitoring records, for example epilepsy and significant behaviours, are maintained up to date to support professional reassessment of needs. The care plans looked at show that the people using this service have regular and routine access to health care services, which includes their GP, dentist, optician and chiropodist. People are offered opportunities to attend routine screening services and a record of the decision is made on their care plan. Medicine management in this home is to a good standard with evidence that competencies of staff when administering medicine to people is regularly monitored. All records relating to medicine management seen on this occasion were up to date and care plans clearly identified the preferred way of the service user when taking their medicine. It was noted that when people are offered their medicine it was explained to them what the medication is and people were given time to take their medicine at a pace appropriate for them. Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use this service are able to express their concerns, and have access to a robust, effective complaints procedure. They are protected from abuse and have their rights protected by through effective policies and procedures. EVIDENCE: Discussion with people using the service and staff and examination of the complaints record for the home demonstrates that there continues to be an open and positive approach regarding this service. The complaints record for the home confirmed that there has been no complaints made about the service since the last inspection and relatives comments on the returned questionnaire indicated they were aware of the home’s complaints procedure been and never had cause to make a complaint. Information for people about how to complain if they are unhappy is available to them in symbol and written format, which enables them to have a good understanding of how to do this. There are policies and procedures in place regarding protection from abuse and possible harm; the most positive safeguard however continues to be the ethos and atmosphere apparent in the home. Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 18 Staff on duty at the time demonstrated a good understanding of their role and responsibility within the policy and procedures for the protection of people from harm and this included reporting any such incident to social services. People living in the home said they felt safe in their environment and with the people who were caring for them. People said that they were able to talk to the manager about things that concerned them. The company has a clear and appropriate policy concerning the management of service user’s finances. One person’s money held in the home was counted and found to be compatible with the record being maintained by staff. People said that the manager looks after their money and that they could have this whenever they wanted. Training information looked out indicates that staff receive regular training in abuse and that this is planned for again in 2007. Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people living in this home have a living environment that is appropriate for their particular lifestyle needs and is homely, clean, safe and comfortable and well maintained. EVIDENCE: There is a warm and welcoming atmosphere in the home and at the time of the visit it was homely, comfortable and safe. People who use the service are encouraged to see the home as their own and are able to move around easily and freely and to go to their bedroom if they wish. People using the service were happy for their bedrooms to be looked at. They said they liked the new flooring in their bedrooms and it was evident that individual choices had been made. People were very comfortable in the way they showed us around the home. They talked about where they used to live and about their family and photographs displayed around the bedroom reflected this. Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 20 Decor, furnishings and fittings were all to a high standard and there is a refurbishment and redecoration programme identified which this year will include replacing the dining-room carpet. Non-slip tiling has been laid downstairs in bathrooms and toilets, the laundry, kitchen and the corridor in this area. Specialist equipment has been provided when necessary and this included handrails in bathrooms and toilets and mobile hoist. There is a domestic staff and laundry person employed by the manager and they are to be complemented on the high level of cleanliness in the home. All areas of the home were well presented and smelt fresh. The laundry room is fitted with domestic appliances, which include a washing machine with a sluice wash facility. The person working in the laundry was able to explain the infection control procedures in the home, which included procedures for the disposal of continence waste. There are established policies and procedures in place for the control of the risk of infection in the home and staff practices during the visit were seen to be safe. Infection control training is included in mandatory training for all staff and when being assessed towards NVQ Level 2.. Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 21 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,34 and 35. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people who live in this home are supported by an effective and competent staff team who have the skills and knowledge to meet their individual and collective needs, which promotes their health and well being. EVIDENCE: The recruitment files for newly appointed staff were looked at and demonstrated appropriate recruitment procedures had taken place. This included confirming satisfactory Criminal Record Bureau checks and obtaining two references, one of which is from the employee’s previous employer. Pre-inspection information looked at prior to the visit to the home demonstrated that there is a comprehensive training programme in place for staff. This includes safe working practices, care of medicines, person centered planning, protection of vulnerable people, Learning Disability Award Framework, (LDAF), Induction. Training in the specific needs of the people living in the home includes Dementia Care and Epilepsy. Autism training is planned for in November 2007. Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 22 There is a rolling programme of assessment of care staff towards an NVQ Level 2 or above and 58 now have an NVQ at Level 2 or above. Observation of care practice and discussion with staff on duty at the time determined that positive relationships exist between people and the staff supporting them. Staff were seen to be approachable by, and comfortable with people, they were good listeners and communicators. Additional comments made by relatives when responding to the comment card sent to them included; • • The staff are jolly and helpful. My husband and I are very happy to know our daughter is well looked after. Other information received indicated that relatives are always made to feel welcome in the home by staff at any time and that there was always sufficient numbers of staff on duty. There is a key worker system in place and people spoken with knew who their key worker was and the names of all staff that were working in the home. All staff were observed to have an understanding of the individual needs of the people living in the home and responded to people appropriately and sensitively. Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 23 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39,41 and 42. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people living in this home continue to benefit from a well run home that has effective systems in place to ensure their health and well-being is promoted and maintained. EVIDENCE: Discussion with people using the service, staff and the manager, examination of home records and observation of care practices demonstrated that the service is managed by a competent and skilled manager who fosters an atmosphere of openness and respect with people, and that staff feel valued and their opinions matter. There are affective quality assurance and monitoring processes in place to ensure the home is meeting the needs of the people living there. Quality Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 24 monitoring covers all areas of the service and includes, training and development of staff, food provision, staffing levels and complaints. Quality assurance records looked at show that the service has a commitment to involving people using the service, relatives and friends, health-care professionals and staff through seeking their views by questionnaire or consultation meetings. The Provider maintains regular contact with people using the service and staff and makes a written report on the running of the service monthly. People said that they regularly meet with the provider of the service to discuss issues in the home. An annual Carers Consultation is held and this includes discussion about future development plans for the service. The service has received many compliments about the care provision and a sample of these included; “We have peace of mind that our relative receives a standard of care which is exemplary.” “Please thank all your staff for the care, patience and encouragement they have given. Without you all a relative would certainly not be as well as she is.” Health and safety management in this home is to a high standard and all records seen relating to this were up-to-date and in good order. Safe practices were observed in the home and records show that this is further promoted through training for staff in manual handling, food hygiene, first aid, fire safety and infection control. Pre-inspection information received shows that maintenance of fire fighting equipment, electrical appliances and central heating systems takes place on a regular basis. Excellent systems are in place for ensuring that food hygiene is maintained and monitored, this includes recording fridge and freezer temperatures and cooked meats. Fire safety management includes regular testing of fire alarms and emergency lighting and all records relating to fire safety management were up-to-date and in good order. Safety procedures are displayed in written and symbol format so that people using the service can understand these. A record is maintained in the home of any accident or incident that happens to a person using the service. All records seen during this visit were stored securely and in good order. Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 25 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 Standard No Score 1 X 2 4 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 X 4 X 4 X 3 4 X Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 YA35 Good Practice Recommendations It would be beneficial for all staff to have training in tissue viability awareness as part of good practice development. Polesworth Group 32 Station Road DS0000004283.V336803.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Polesworth Group 32 Station Road DS0000004283.V336803.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. 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