CARE HOME ADULTS 18-65
Polesworth Group - Long Street, 64&66 64 & 66 Long Street Dordon Warwickshire B78 1SL Lead Inspector
Maggie Arnold Unannounced Inspection 24th January 2006 12:45 Polesworth Group - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 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 - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 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 - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Polesworth Group - Long Street, 64&66 Address 64 & 66 Long Street Dordon Warwickshire B78 1SL 01827 895073 01827 892500 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 Mr Stewart Harrison Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Polesworth Group - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 16th August 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 to adults with learning disabilities. 64/66 Long Street is a care home for six service users situated in Dordon near Tamworth. The property is two terraced houses that have been knocked into one to provide Dordon Group Home and is unidentifiable as a care home blending into surrounding residential properties. Service users accommodation is located on the ground and first floor, the first floor being accessed via two staircases. The home offers four single bedrooms and one double bedroom with a shower and toilet en/suite. There is a very attractive bathroom with toilet on the first floor and a shower room with toilet on the ground floor. The ground floor also provides a small utility/laundry area, a large bright conservatory that is used as a dining area and hobbies/activities room. There is a large comfortable lounge with a variety of seating that is comfortably furnished and is domestic in style. There is also a staff sleeping in room. Externally there is a patio area, lawn, garden, brick and wooden sheds all at the rear along with some car parking space. Dordon Group home operates as a family style home with service users being involved in daily living routines and general household tasks where able to do so. Polesworth Group - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a weekday between the hours of 12.45pm and 4.50pm. One staff member was on duty at the time of the inspection. There was a staff handover during the course of the inspection. All of the residents were out for the day arriving home about 4.00pm. The manager was available for part of the inspection process. What the service does well: What has improved since the last inspection?
Only two recommendations arose from the last inspection. As noted in the section above these have been implemented. Polesworth Group - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 Page 6 What they could do better:
The main area of concern arising from this inspection is the poor management of the medication. A sample of medication and accompanying records highlighted a number of serious discrepancies. Areas of concern are as follows: No discrepancies were noted by the staff at the time a new supply medication was checked into the home. The inspector was informed that a tablet was missing from the monitored dosage system (MDS) when a staff member came to issue the Monday morning medication. There were no records to demonstrate what steps had been taken to investigate how or why a tablet from a MDS came to be missing. The morning tablets for Monday 23rd of January 2006 had been removed from the monitored dosage system. The corresponding medication administration record (MAR) sheets for all of the medications issued were not completed to confirm whether the medication had been issued to the residents. Individual resident’s MAR sheets must be signed as the medication is issued to each resident. Gaps in MAR sheets must not be discretely completed in retrospect. The MAR sheets and resident’s records must clearly record that there has been a discrepancy. The records must confirm whether the medication had been issued and by whom. A resident’s MAR sheet recorded that she had been prescribed a particular medication, which she was to take as required (PRN). The MAR sheet, which was started on Monday 23rd January 2006, did not record how many tablets were remaining. The pharmacist’s label showed that the boxed tablet had been issued on 16th of December 2002 and were out of date since June 2005. The home must ensure that records are maintained of the quantities of both prescription and homely medication held by the home. The home must routinely check that medication is not out of date. The home was applying a non-prescription treatment for corns as advised by the resident’s chiropodist. The drops had been out of date since November 2005. It was difficult to establish from the healthcare records whether the treatment had been in continuous use since it commenced in June 2005. Detailed records must be maintained of any such treatments. The home holds a variety of homely medicines. Records of the type and quantities of the homely medication are recorded in a hard backed book. A number of the homely medication preparations were out of date. The home must take steps in order ensure homely medications are safe to take with prescription medication. Advice was given as to how the homely medication records might be improved. Prescription medication is kept in a locked cupboard within a large multi purpose locked cupboard. Homely medication in stored next to the medication
Polesworth Group - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 Page 7 cupboard on an open shelf in the large cupboard. Homely medication must be stored in the same manner as prescription medication. 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 - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 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 - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this occasion. EVIDENCE: With the exception of Standard 5, this section was assessed at the time of the previous inspection and found to meet the National Minimum Standards. Polesworth Group - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 Page 10 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 the following standard(s): 6 Care plans, developed in liaison with the residents, helps to ensure that residents can be confident that their assessed and changing needs are met. EVIDENCE: With the exception of Standard 6, this section was assessed at the time of the previous inspection and found to meet the National Minimum Standards. One care plan and accompanying records were examined on this occasion. A detailed Social Services Care Management Assessment plan was held on the resident’s personal file. The plan covered all aspects of personal, social support and healthcare needs. Neither the resident nor social worker had signed the Care Management Assessment plan. The care plan and records were orderly, up to date and easy to crossreference. The records demonstrated that the resident was involved in decisions about her care and daily routine. Advice was given regarding how the records might be further improved. For example, records could be further improved by recording more details of positive feedback from the residents. The home has been pro active in supporting a resident to lose some excess
Polesworth Group - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 Page 11 weight. A staff member said that the resident was very pleased with her steady weight loss but this was not recorded on her file. Polesworth Group - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 12, 13 & 17 The home enables residents to participate in appropriate activities both within the home and local community. This promotes a sense of identity and wellbeing. The residents’ health and wellbeing is promoted by nutritious and varied meals. EVIDENCE: All of the residents are encouraged to participate in valued and fulfilling activities. On the day of the inspection two residents were at college and the remaining four residents were attending a day care provision. The inspector had the opportunity to talk to all six residents who confirmed that they had enjoyed their day and liked their weekly routines. Activities included, knitting, soft toys and embroidery as well as computing and cookery lessons. One of the residents attends a flower arrangement class. The results of her work were on display in the home.
Polesworth Group - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 Page 13 The home supports the residents to participate in community life. For example three of the residents attend a church service on Sundays. Residents regularly go bowling and visit the cinema and theatre. The inspector was advised that tickets have been booked for the residents to see a musical show in February. Key workers accompany individual residents on shopping trips for clothes and gift shopping. Residents are encouraged to eat a nutritious and varied diet. The home has menu plan. Records are also maintained of residents’ daily choices. The kitchen was very clean and free from clutter. There were ample supplies of varied foodstuffs, which were appropriately stored. Refrigerator and freezer temperatures are routinely checked. Subject to risk assessments all of the residents assist in the preparation and serving of drinks and meals. It is common practice for staff and residents to eat their meals together. Most meals are taken in the large pleasant conservatory that leads directly off the kitchen. The residents said that they were involved in menu planning. Residents also confirmed that they helped with food preparation and various tasks including setting and clearing the table. Discussions evidenced that the residents had particularly enjoyed the food and activities at Christmas, New Year and a recent birthday celebration. Polesworth Group - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 18 & 20 Residents’ privacy and dignity is compromised by poor staff practice. The failure to adhere to the home’s medication policies and procedures compromises the residents’ health and welfare. EVIDENCE: Standard 18 was met in full at the time of the last inspection. As on the previous inspection all of the residents were well groomed and appropriately dressed for the weather. Residents’ clothing, hairstyles and jewellery reflected their individual personality and preferences. It was noted that staff had left beautifully laundered items of clothing, including underwear, on a chair in the conservatory. The laundry was on view to two visiting residents from numbers 68 and 70 Long Street who were having lunch in the home. Such practice compromises the privacy and dignity of the residents living in the home. The home has a monitored dosage system (MDS) and accompanying daily medication administration record (MAR) sheets for the management of the residents’ medication. The pharmacist issues tablets that are not suitable to be stored in a MDS in the traditional manner. Scrutiny of the medication found
Polesworth Group - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 Page 15 the management of the medication to fall below an acceptable standard. For example, the morning tablets for Monday 23rd of January 2006 had been removed from the monitored dosage system. The corresponding MAR sheets were not completed to confirm that the medication had been given to the residents. A resident’s MAR sheet recorded that she had been prescribed a particular medication, which she was to take as required (PRN). The MAR sheet, which was started on Monday 23rd January 2006, did not record how many tablets were remaining. The pharmacist’s label showed that the boxed tablet had been issued on 16th of December 2002 and were out of date since June 2005. A number of homely medicines were also out of date. Polesworth Group - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 Page 16 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 the following standard(s): 22 & 23 The clear complaints procedures ensure that residents’ views are listened to and acted on. The risk of residents being financially abused is minimised by the home’s policies and procedures. EVIDENCE: The home has a robust complaints procedure that helps to ensure that residents concerns are listened to and acted on. Neither the home nor the Commission have received any complaints about the service since the previous inspection. The home has a number of systems in place that work towards encouraging residents’ to give feedback about the quality of care and support they receive. For example, the Chief Executive of Polesworth Group Homes meets with the residents on a three monthly basis. The manager and staff are excluded from these meetings. Annual questionnaires and six monthly reviews also offer an opportunity for individual resident’s views to be heard. Residents spoken to on the day of the inspection said that if they were not happy they would let the staff know or “Talk to Betty (the Chief Executive of Polesworth Group Homes) or Stuart (the manager)”. The previous inspection report recommended that, whenever possible, two members of staff sign receipts for monies spent on residents’ behalf. This recommendation has been implemented. A check of the residents’ personal allowances found that, with one minor exception, records and balance of the monies to be correct. Although the balance of monies was correct, a staff
Polesworth Group - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 Page 17 member had omitted to complete full details of the amount of money on the home’s records. A shopping receipt confirmed that the amount of money spent came to the value of £7.60 and not £7.00 as recorded. It is recommended that individual records note where shared receipts are held. On the day of this inspection, the manager cancelled any future visits from a mobile hairdresser who failed to provide evidence that she was insured to carry on the work. Polesworth Group - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 Page 18 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 the following standard(s): Not assessed on this visit. EVIDENCE: This section was fully accessed at the time of the previous inspection which took place in August 205. On that visit Standards 24 to 29 met the National Minimum Standards. Standard 30 exceeded the National Minimum Standards. Two residents showed the inspector their bedrooms and the communal areas. The good-sized bedrooms were decorated and furnished to a high standard. Both bedrooms clearly reflected the personality and interests of the individual occupants. Communal areas continue to be homely, clean and hygienic. Polesworth Group - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this visit. EVIDENCE: All of the Standards were assessed at the time of the previous inspection and were found to fully meet the National Minimum Standards. During the course of the inspection visit two staff members were spoken to. Both staff members were cooperative in the inspection process and readily acknowledged shortfalls in the overall management of the medication. Polesworth Group - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 39 A suitably qualified and competent manager manages the home. This helps to ensure the home is well run and the safety and well being of the residents is promoted. Residents are confident that their views underpin all self-monitoring, review and development by the home. EVIDENCE: In addition to 64-66 Long Street the registered care manager is also responsible for Numbers 68 and 70 Long Street, which are two adjoining Polesworth Group Homes. The manager, who has worked for the company since 1997, holds National Vocational Qualifications (NVQ) at Levels 3 and 4 in Care, a City& Guilds Advanced Management in Care as well as a Registered Managers Award. Polesworth Group - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 Page 21 Additionally the manager has recently commenced a postgraduate Diploma in Management Studies. The home has a number quality assurance and monitoring systems in place. For example, the Chief Executive of the Polesworth Group Homes visits the residents four times a year. The manager and staff are excluded from these formal meeting. The manager advised, although feedback is given, the Director retains the records of the meetings. In accordance with the Care Homes Regulations 2001: Regulation 26 a representative of the Company also makes regular unannounced visits to the home. A copy of the findings of the Regulation 26 visit is forwarded to the Commission. The manager receives regular formal supervision and an annual appraisal from the Chief Executive of the Company. An annual performance review helps to monitor the standard of the service over the previous twelve months and agree on development plans for the forthcoming year. The meetings and visits help to ensure the accountability of the manager and staff and that the service is run in a manner that takes into account the views of the residents. Polesworth Group - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 Page 22 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 x 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 3 23 3 ENVIRONMENT Standard No Score 24 x 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 x 33 x 34 x 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 x x x x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 x 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 x 2 x 3 x 3 x x x x Polesworth Group - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 Page 23 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 Standard YA18 Regulation 12 (4) (a) Requirement Timescale for action 28/02/06 2 YA20 13 (2) The registered person must make arrangements to ensure that the care home is conducted in a manner that respects the privacy and dignity of the residents. The registered person shall make 28/02/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medications received into the care home. Polesworth Group - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 Page 24 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 YA23 Good Practice Recommendations It is recommended that individual records note where shared receipts are held. Polesworth Group - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Leamington Spa Office 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 - Long Street, 64&66 DS0000004329.V280116.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
