CARE HOME ADULTS 18-65
Polesworth Group - Friary Road, 8 8 Friary Road Atherstone Warwickshire CV9 3AG Lead Inspector
Cathrine Mundy Unannounced 20 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Polesworth Group - Friary Road, 8 E53 s4281 PG Friary Rd v240455 200705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Polesworth Group - Friary Road, 8 Address 8 Friary Road Atherstone Warwickshire CV9 3AG 01827 718066 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Polesworth Group Homes Mrs Leigh-Anne Smith PC Care home only 6 Category(ies) of LD Learning disability (6) registration, with number of places Polesworth Group - Friary Road, 8 E53 s4281 PG Friary Rd v240455 200705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: There are no conditions of registration. Date of last inspection 9th March 2005 Brief Description of the Service: 8 Friary Road is a registered care home providing 24-hour personal support to six adults with learning disability. Friary Road was established in 1992 and is part of Polesworth Group Homes Limited, a voluntary organisation and registered charity. 8 Friary Road is a large semi-detached house situated on the outskirts of the small market town of Atherstone in Warwickshire and close to all local services and facilities. There are six single bedrooms; each service user has their own room, which contains a wash hand basin. Shared space comprises of a spacious kitchen, a large lounge with dining area, and utility room. There are three bedrooms on the ground floor, a shower room and bathroom with shower, bath, toilet and wash hand basin. There are three further bedrooms on the first floor of the house, and the staff sleepover/office room. There is a further bathroom with toilet, basin and shower cubicle on the first floor. The premises are well maintained. Decor, furniture and fittings are of a good quality. Outside there is a driveway and car parking to the front of the property and to the rear, a spacious private garden, which is well maintained and includes a vegetable patch, patio area, shed and greenhouse. Polesworth Group - Friary Road, 8 E53 s4281 PG Friary Rd v240455 200705 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 20th July 2005, between the hours of 3.15 pm and 6.45 pm. During this time the inspector had the opportunity to spend time with the residents, meet two staff members, tour the premises and examine files relating to the residents and other documentation available in the home. The inspection was supported by the Registered Manager. What the service does well:
The feedback received from the residents was extremely complimentary of the service that is provided. The residents stated that they were happy and enjoyed living in the home. Observations of the interactions between the residents, the staff and their environment indicated that the residents were comfortable and relaxed. The staff team have worked in the home for a number of years. It is clear that the staff and residents have developed positive relationships. The home continues to provide the residents with an individual plan of care which meets their identified needs, the staff showed that they are able to meet the residents needs effectively, whilst promoting the residents privacy and dignity. Where appropriate risk assessments have been completed. Risk management strategies have been developed to meet the risks identified. Referrals to the relevant healthcare professionals are made as required. The home demonstrated that it has supported the residents to access these services. The residents continue to access a broad range of appropriate activities of their choice, during the day, in the evening and at weekends. Day time activity is arranged to reflect the needs and wishes of the residents. The residents attend structured placements during the day time, from this they access work opportunities and attend college courses, some of the residents have received certificates for their achievements. The home continues to support the residents to maintain links with family and friends. The quality of the service that is provided is regularly monitored. This includes analysis of complaints, staff turn over and ill health, and accidents and incidents. The home also seeks the views of the residents, their relatives and the staff. The feedback provided is listened to and acted upon. The residents also have opportunity to raise concerns at the house meetings, which take place on a regular basis. The residents stated that the staff are approachable, they feel confident that any concerns raised would be addressed. Polesworth Group - Friary Road, 8 E53 s4281 PG Friary Rd v240455 200705 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Polesworth Group - Friary Road, 8 E53 s4281 PG Friary Rd v240455 200705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Polesworth Group - Friary Road, 8 E53 s4281 PG Friary Rd v240455 200705 Stage 4.doc Version 1.40 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3 and 4 The residents are provided with sufficient information which details the services provided in the home. The home has acceptable admissions procedure, this provides prospective residents with sufficient information prior to making a decision to move in to the home, and enables the home to make an informed decision as to whether the residents identified needs can be met. EVIDENCE: The home has a Statement of Purpose which details the services provided in the home. Each of the residents have been issued with a Service Users Guide to the home and a contract detailing terms and conditions of residency. The residents hold these documents, they were not examined during this inspection, as it has been noted at previous inspections that these documents are acceptable. The file relating to the resident who has most recently moved in to the home was examined. This provided evidence that an appropriate admissions procedure had been followed, including introductory visits, liaison with the residents family and other professionals involved in the provision of care, an assessment of needs and development of an individual plan of care. The resident confirmed that he is happy with his placement in the home. There are currently no vacancies within the home.
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The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 9 The care planning system in place is good, providing the staff with sufficient information to enable them to meet the residents identified needs. EVIDENCE: The residents are provided with a plan of care which details the actions to be taken by the home in order to meet their identified needs and wishes. Risk assessments have been completed and risk management strategies have been developed to address the risks identified. Both the care plan and risk assessments are subject to regular review. Polesworth Group - Friary Road, 8 E53 s4281 PG Friary Rd v240455 200705 Stage 4.doc Version 1.40 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 The residents are supported to participate in valued and fulfilling activities which they enjoy. The residents are able to maintain appropriate relationships with their family and friends. EVIDENCE: The residents are supported to take part in valued and fulfilling activities, during the day, in the evenings and at weekends. All of the residents attend a structured day placement on week days. It is advised that from their placement the residents access work opportunities and attend college courses, these include horticulture, cookery and car maintenance. The residents were proud that they had received certificates of achievement following completion of these courses. One of the residents has also achieved an NVQ qualification in cookery. The home has taken appropriate action to support one resident who indicated that he did not wish to attend his previous placement. A referral has been made to the advocacy service to support this resident to identify a more suitable placement. Polesworth Group - Friary Road, 8 E53 s4281 PG Friary Rd v240455 200705 Stage 4.doc Version 1.40 Page 12 Leisure opportunities available in the evenings and at weekends include going to the pub, having meals out, visiting family and friends, listening to music, watching television, and relaxing at home. Some of the residents have entered a bowls tournament and were optimistic about their chances of winning the semi- finals, which were to take place in the week following the inspection. The residents confirmed that they had all recently been on holiday, which they enjoyed. They were keen to show the inspector their photographs. Some of the residents had also been on holidays with their families. The home supports the residents to maintain contact with their families and friends, the home welcomes visitors. The residents are also supported to visit their families. The residents are able to meet with their visitors in private if they wish. This is subject to individual risk assessment, restrictions are agreed with the resident and detailed in their individual plan of care. Polesworth Group - Friary Road, 8 E53 s4281 PG Friary Rd v240455 200705 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 The residents personal care needs are met in a way which reflects their personal choice, and promotes their privacy, dignity and independence. The home seeks appropriate support from the relevant health care professionals to ensure that the residents healthcare needs are identified and met. The systems in place for the management of the residents medication are good, clear guidance is in place to ensure that the residents medication needs are met. EVIDENCE: The residents preferred daily routines are clearly detailed in their individual plans of care. These confirmed that the residents privacy, dignity and independence is respected. The interactions observed during this inspection also confirmed this. The plans of care also detail the residents health care needs. Records are made of any contact with healthcare professionals and any incident, which may affect the residents health. The outcome for the resident is also recorded. The Registered Manager confirmed that referrals are made to the appropriate health care professional to ensure that the residents health needs are identified. Strategies are in place to meet the needs identified. This is evident
Polesworth Group - Friary Road, 8 E53 s4281 PG Friary Rd v240455 200705 Stage 4.doc Version 1.40 Page 14 in the residents individual plans of care. The home is appropriately supporting one resident who is currently unwell. The needs of the residents are such that the home maintains responsibility for the management of the residents medication. The procedures in place for storage, administration and recording continue to reflect good practice. The home has recently introduced a homely remedies policy. This enables the residents to receive medication for minor ailments safely. Polesworth Group - Friary Road, 8 E53 s4281 PG Friary Rd v240455 200705 Stage 4.doc Version 1.40 Page 15 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The home has an acceptable complaints procedure in place, the residents are confident that the concerns they raise will be listened to and acted upon. The homes policies and procedures protect the Service Users from abuse. EVIDENCE: The home has an acceptable complaints procedure in place. This details the actions to be taken by the staff, manager and organisation in order to resolve any complaints made or concerns raised. The homes complaints log indicated that there have been no complaints made since the time of the last inspection. The complaints procedure is also provided in a format that is more accessible to the residents, this is displayed prominently within the home. The residents confirmed that should they wish to make a complaint or raise a concern they would feel confident in discussing this with their key worker, the Registered Manager or a representative of the organisation. The residents indicated that they were confident that any concerns raised would be addressed. The home also facilitates regular house meetings, the residents and staff confirmed that these also provide a forum for the residents to raise concerns. The home has an adult protection and whistle blowing policy in place. These were available in the home and are provided as part of the staff handbook. The Registered Manager demonstrated that in the event of abuse being suspected appropriate procedures would be followed. All of the staff working in the home have received training in the protection of vulnerable adults. The financial records relating to one resident were examined. These indicated that the residents monies are handled appropriately by the home.
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The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 The standard of the environment is good, providing a comfortable and homely place to live. EVIDENCE: The communal areas of the home are comfortable, clean and homely. Décor and furnishings are of good quality and well maintained. To respect the residents privacy the inspector did not access the residents bedrooms as the residents were, at the time of the inspection getting ready to go out for a meal. These were seen at the time of the last inspection, when it was noted that the residents bedrooms were decorated and furnished to reflect the residents individual personalities and their needs and wishes. The lock currently provided in the first floor bathroom is a bolt, which although provides the residents with privacy would not enable the staff to support the residents in the event of an emergency. This lock must be changed. Polesworth Group - Friary Road, 8 E53 s4281 PG Friary Rd v240455 200705 Stage 4.doc Version 1.40 Page 18 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35 and 36 The residents are supported by a team of staff which are appropriately trained and supported, in order that the residents needs are met effectively. EVIDENCE: The home employs four staff members, all of which have been in post for a number of years. It was clear from the interactions between the staff and residents and from discussions with the residents that positive relationships have been formed. The residents are supported by one member of staff. These staffing ratios are appropriate to the needs of the residents. To promote the health and safety of the staff a lone working policy has been devised. Examination of the training records confirmed that the staff have received training relevant to their role. In addition the staff receive regular formal supervision and annual performance appraisal. The Registered Manager is also responsible for another home within the organisation. She advised that she spends up to three days in the home each week, this is organised flexibly to meet the needs of the service. The Registered Manager also maintains daily telephone contact with the home and allocates periods of time to spend with the residents. This level of support is appropriate for the needs of the home. The home adopts appropriate recruitment practices which protect the residents.
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The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39 and 42 Appropriate monitoring and assessment of risk is undertaken to ensure that the health and safety of the residents and staff is promoted and maintained. The home regularly reviews its performance through a good programme of self-review and consultations with residents, their relatives and staff. It is evident that the views expressed are listened to and acted upon. EVIDENCE: The Registered Manager demonstrated her competency to fulfil her role effectively throughout this inspection. The home monitors the quality of the service that is provided. This includes consultation with residents, their relatives and staff, in completion of satisfaction questionnaires. There is evidence that the views expressed are acted upon. It is recommended that the home seeks an advocate who is independent to the home to support the residents to complete these questionnaires in the future. In addition the home monitors its performance with regard to staff turn over, absence due to ill health, training and analysis
Polesworth Group - Friary Road, 8 E53 s4281 PG Friary Rd v240455 200705 Stage 4.doc Version 1.40 Page 21 of accidents and incidents. A report is complied annually to reflect this monitoring, the outcome informs the homes annual development plan. The home is visited by a representative of the organisation, under Regulation 26 of the Care Homes Regulations 2001, each month. A copy of the report made following each visit is forwarded to Commission for Social Care Inspection. The home takes appropriate action to promote the health and safety of the residents and staff. This is in the monitoring of fire equipment, electrical and gas appliances and the completion of risk assessments and provision of risk management strategies. The home adopts good food hygiene practices, which reduce the risk of ill health to the residents. Monitoring of food storage temperatures and the temperatures of meals as they are served is maintained and recorded. Water outlets are fitted with thermostatic controls to reduce the risk of scalding. These are serviced annually. In addition the home randomly monitors water temperatures. It is recommended that these are recorded. Polesworth Group - Friary Road, 8 E53 s4281 PG Friary Rd v240455 200705 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 x Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 x x 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score x 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Polesworth Group - Friary Road, 8 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 3 x E53 s4281 PG Friary Rd v240455 200705 Stage 4.doc Version 1.40 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 24 Regulation 13(4)(c ) Requirement The lock to the first floor bathroom is to be changed to enable staff to access the bathroom in the event of an emergency. Timescale for action 31/8/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 39 42 Good Practice Recommendations It is recommended that the home seek advocacy which is external to the home to support the residents when completing satisfaction questionnaires. The home should make records of the monitoring of water temperatures. Polesworth Group - Friary Road, 8 E53 s4281 PG Friary Rd v240455 200705 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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