Inspection on 14/03/05 for Polesworth Group 70 Long Street

Care Homes For Adults (18 ­ 65)Polesworth Group - Long Street, 7070 Long Street Dordon Tamworth Warwickshire B78 1SLUnannounced Inspection14th March 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Polesworth Group - Long Street, 70 Address 70 Long Street, Dordon, Tamworth, Warwickshire, B78 1SL Email address Tel No: 01827 895125 Fax No: 01827 892500Name of registered provider(s)/company (if applicable) Polesworth Group Homes Limited Name of registered manager (if applicable) Mr Stewart Harrison Type of registration Care Home No. of places registered (if applicable) 3Category(ies) of registration, with (number of places) Learning disability (3) Registration number E040000211 Date first registered 29th May 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 19th May 2003 YES NO 16/11/04 If Yes refer to Part CPolesworth Group - Long Street, 70Page 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 314th March 2005 11:30 am Patricia Flanaghan Yvette DelaneyID Code074640 071603Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionPolesworth Group - Long Street, 70Page 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementPolesworth Group - Long Street, 70Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Polesworth Group - Long Street, 70. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Polesworth Group - Long Street, 70Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 70 Long Street, also known as The Cottage is part of Polesworth Group Homes, which was established as a Limited Company in June 1991, with the aim of providing accommodation and support services to adults with learning disabilities. The home is one of three care homes housed in adjoining terraced properties owned by the company on Long Street.70 Long Street accommodates two service users. It comprises of a modern kitchen with utility at the rear, a cosy dining room and lounge. On the first floor there is one large bedroom and another smaller bedroom and a light modern bathroom. Externally there is a small rear garden with lawn, flower-beds and shrubs. The home is situated in a residential area of Dordon near to shops and other local facilities including a public house, a library and a health centre. As the current service users are able to safely maintain many aspects of their independence, 70 Long Street is only staffed for parts of the day. Staff are available 24 hours a day at 64-66 Long Street and the service users from 70 Long Street can call upon these staff should a need arise.Polesworth Group - Long Street, 70Page 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The focus of inspections undertaken by the Commission for Social Care Inspection is upon the views and experiences of service users, and the ability of the service to support and promote their health and wellbeing. This is the second inspection of this service in the 2004/05 Inspection Year. Linked to the Commissions focus on service user experience and proportionate inspection, this inspection will focus on requirements outstanding from the last inspection of this service on 16th November 2004 and National Minimum Standards that have the greatest direct impact on the health, wellbeing and opportunities of service users. Choice of Home (Standards 1 to 5) As noted at the last inspection visit the level of information available in the home is adequate and presented in a style suitable to the service users living in the home. There is a pictorial and photographic statement of purpose and service user guide. Staff were able to demonstrate that they could meet the needs of service users currently living in the home. Individual Needs and Choices (Standards 6-10) This section was not assessed during this inspection. It was evident, however, that the home continues to ensure that service users are supported to be independent and involved in all aspects of community living. Lifestyle (Standards 11-17) This section was not assessed during this inspection. As noted at the previous inspection opportunities are available to service users enabling them to maintain and develop social, emotional, communication and independent living skills and so promote personal development. Discussion with staff on duty at the time of the inspection visit indicates that service users continue to be encouraged and supported to integrate fully in the local community. Personal and Healthcare Support (Standards 18-21) Observation and discussion with staff and details in care plan documentation, demonstrated their flexibility and acknowledgement of the level of support required by individual service users to maximise their privacy, dignity, independence and control over their lives. Examination of records and discussion staff evidenced that service users are encouraged to retain and control their own medication if appropriate and assessed as capable. Concerns, Complaints and Protection (Standards 22-23) Polesworth Group - Long Street, 70 Page 6 Polesworth Group Homes have procedures in place to ensure that complaints are dealt with effectively. Staff had been provided with training in adult protection and understanding and managing behaviours that may challenge. Environment (Standards 24-30) Observation of the environment evidenced that the home continues to be suitable for and meets the needs of service users resident in the home, is safe and well maintained. Furniture and fittings in all bedrooms are appropriate to meet the individual needs of service users. Bedrooms are decorated to a high standard and furniture and fittings are of a high quality. Service users are enabled to have a say in how the house is decorated. Staffing (Standards 31-36) The home continues to be staffed by a small, dedicated team, appropriately trained and with an in-depth knowledge of the service users. Conduct and Management of the Home (Standards 37-43) This section was not assessed during this inspection. It was evident, however, that the manager and staff continue to ensure that the health, safety and welfare of service users are promoted as far as reasonably practicable within a risk management framework. Since the last inspection the home has fitted suitable door closure devices, which comply with fire regulations.Polesworth Group - Long Street, 70Page 7 Requirements from last Inspection visit fully actioned?NACONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Polesworth Group - Long Street, 70Page 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action The Registered Manager must ensure that supervision of care staff includes addressing the matters discussed in Standard 36. 1 18(2) YA36 The standard could not be assessed at this inspection visit as the registered manager was not present. The requirement set at the inspection visit on 16/11/04 is therefore carried forward to the next inspection. 30/06/05Polesworth Group - Long Street, 70Page 9 RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard ** Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.Polesworth Group - Long Street, 70Page 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO NO NO NO NO NO NO NO NO NO YES NO NO NO NO YES NO YES 0 0 0 NA NA YES YES X X 14/03/05 11:30 3Polesworth Group - Long Street, 70Page 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Polesworth Group - Long Street, 70Page 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. X X Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are 0 Key findings/Evidence Standard met? This standard was met at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 0 Key findings/Evidence Standard met? This standard was exceeded during the previous years inspection, and was not assessed on this occasion. It should be noted that there have been no new service users admitted this home since the last inspection visit on 16/11/04. From evidence presented at the previous inspection visit and from discussions with staff at this visit, inspectors consider this standard continues to be met.Polesworth Group - Long Street, 70Page 13 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? This standard was met at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met? This standard was met at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 0 Key findings/Evidence Standard met? This standard was exceeded during the previous years inspection, and was not assessed on this occasion.Polesworth Group - Long Street, 70Page 14 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 0 Key findings/Evidence Standard met? This standard was met at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 0 Key findings/Evidence Standard met? The standard could not be assessed at this inspection visit, as the registered manager was not present. Following the inspection of 16/11/04, the manager advised the CSCI that service users understanding and agreement is now sought in respect of the management of finances. . It is also understood that a protocol regarding appointeeships is now seeking final approval prior to being implemented by the organisation.Polesworth Group - Long Street, 70Page 15 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 0 Key findings/Evidence Standard met? This standard was exceeded during the previous years inspection, and was not assessed on this occasion.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 0 Key findings/Evidence Standard met? This standard was met at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 0 Key findings/Evidence Standard met? This standard was met during the previous years inspection, and was not assessed on this occasion.Polesworth Group - Long Street, 70Page 16 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 0 Key findings/Evidence Standard met? This standard was met at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 0 Key findings/Evidence Standard met? This standard was met at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Polesworth Group - Long Street, 70Page 17 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 0 Key findings/Evidence Standard met? This standard was met at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 0 Key findings/Evidence Standard met? This standard was exceeded at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? This standard was met at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? This standard was met at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Polesworth Group - Long Street, 70Page 18 Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? This standard was met at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Polesworth Group - Long Street, 70Page 19 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 0 Key findings/Evidence Standard met? This standard was met at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) 004 Key findings/Evidence Standard met? An examination of service user records and a discussion with a senior carer demonstrated that health needs are identified and service users have access appropriate health care professionals. Inspectors were advised that the home has a good relationship with the local GP surgery. The senior carer advised inspectors that service users are encouraged to make decisions about dental treatment, medical treatment and health screening facilities in the local area. Service users are supported to attend out-patient appointments. Evidence was presented of the commitment of a senior carer to supporting a service user who will shortly be undergoing medical treatment.Polesworth Group - Long Street, 70Page 20 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 0 Key findings/Evidence Standard met? This standard was met at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? This standard was met during the previous years inspection, and was not assessed on this occasion.Polesworth Group - Long Street, 70Page 21 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 0 0 0 0 0 X 0 Key findings/Evidence Standard met? This standard was met at the time of the previous inspection on 16/11/04 and was not assessed on this occasion. The complaints policy and procedure should be updated to include the address and telephone number of the Commission for Social Care Inspection (CSCI) instead of the National Care Standards Commission (NCSC).Polesworth Group - Long Street, 70Page 22 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES00 Key findings/Evidence Standard met? This standard was met at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Polesworth Group - Long Street, 70Page 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? This standard was exceeded at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Polesworth Group - Long Street, 70Page 24 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite YES NO NO 2 0 0 0 2 10 0 0 00 Key findings/Evidence Standard met? This standard was exceeded at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Polesworth Group - Long Street, 70Page 25 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 0 Key findings/Evidence Standard met? This standard was exceeded at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 0 Key findings/Evidence Standard met? This standard was met at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? The home is small, homely type dwelling and includes a garden with a small patio area. There is a lounge, dining room and bathroom. The kitchen has a separate utility area with a washing machine, dryer and fridge/freezer. There is sufficient space in the home for service users to have privacy if they wish. All areas are accessible to the service users. There was evidence of quality furniture and electrical equipment throughout the home. All areas in the home are attractively decorated and well maintained. There is no `sleep-in room at the home as the home is only staffed for short periods during the day. Staff are available at 64/66 Long Street at other times should service users require support.Polesworth Group - Long Street, 70Page 26 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 0 Key findings/Evidence Standard met? There is no assessed need for specialist equipment to be used in the home.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? All areas of the home were found to be clean and odour free. It was evident that the overall standard of cleanliness throughout the home is very high. Laundry facilities are sited in a utility area at the side of the kitchen. It was advised that dirty laundry is carried through the kitchen in laundry bags only when food is not being prepared. Hand washing facilities are provided in the utility area and floor and wall surfaces are readily cleanable.Polesworth Group - Long Street, 70Page 27 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? This standard was met at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 0 Key findings/Evidence Standard met? This standard was met during the previous years inspection, and was not assessed on this occasion.Polesworth Group - Long Street, 70Page 28 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXX0 Key findings/Evidence Standard met? This standard was met at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This standard could not be assessed at this inspection visit, as the registered manager was not present.Polesworth Group - Long Street, 70Page 29 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This standard was met at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 0 Key findings/Evidence Standard met? The standard could not be assessed at this inspection visit, as the registered manager was not present. The requirement set at the inspection visit on 16/11/04 is therefore carried forward to the next inspection.Polesworth Group - Long Street, 70Page 30 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. YES0 Key findings/Evidence Standard met? This standard was exceeded at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was exceeded during the previous years inspection, and was not assessed on this occasion.Polesworth Group - Long Street, 70Page 31 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? This standard was met during the previous years inspection, and was not assessed on this occasion.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? This standard was met at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met ? This standard was met during the previous years inspection, and was not assessed on this occasion.Polesworth Group - Long Street, 70Page 32 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 0 Key findings/Evidence Standard met? This standard was met at the time of the previous inspection on 16/11/04 and was not assessed on this occasion.Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? This standard was met during the previous years inspection, and was not assessed on this occasion.Polesworth Group - Long Street, 70Page 33 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorPatricia Flanaghan Yvette DelaneySignature Signature SignatureRegulation Manager Susan Houldey Date 8 April 2005Public reports It should be noted that all CSCI inspection reports are public documents. Polesworth Group - Long Street, 70 Page 34 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 14 March 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possible We are working on the best way to include provider responses in the published report. In the meantime responses received are available on request.Action taken by the CSCI in response to provider comments: Polesworth Group - Long Street, 70 Page 35 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 12th May 2005 which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here Polesworth Group - Long Street, 70Page 36 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I, Stewart Harrison of 70 Long Street, Dordon confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I, Stewart Harrison of 70 Long Street, Dordon am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Polesworth Group - Long Street, 70Page 37 Polesworth Group - Long Street, 70 / 14th March 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000004375.V216646.R01© This report may only be used in its entirety. 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