Inspection on 22/05/07 for Polesworth Group Friary Road

This inspection was carried out on 22nd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Polesworth Group Friary Road 08/09/09

Polesworth Group Friary Road 21/02/06

Polesworth Group Friary Road 20/07/05

Polesworth Group Friary Road 09/03/05

Polesworth Group Friary Road 13/10/04

Polesworth Group Friary Road 16/02/04

Similar services:

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

1a White Ladies Close

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

CARE HOME ADULTS 18-65 Polesworth Group Friary Road 8 Friary Road Atherstone Warwickshire CV9 3AG Lead Inspector Sheila Briddick Key Unannounced Inspection 22nd May 2007 03:30 Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Polesworth Group Friary Road Address 8 Friary Road Atherstone Warwickshire CV9 3AG 01827 718066 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 Mrs Leigh-Anne Smith Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2006 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 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, greenhouse and summer house. The current scale of charging is £333 - £633. Additional costs that have to be met by service users include toiletries, outings, holiday spending money and hairdressing Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for service users and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Prior to the inspection visit the manager had forwarded to the Commission a pre-inspection questionnaire, a staffing rota, training information and menu records for the home. Service user and relative questionnaires were sent out and four service user and two relative responses returned. All pre-requested documentation returned was examined as part of the inspection process and the evaluation included in this report. The inspection visit was unannounced and took place over two visits. The first visit took place early evening on Tuesday, May 22, 2007 at 3.30 pm and ended at 5.30pm. A second visit was made the following morning, Wednesday, May 23l at 09.30am, to look at records and meet with the manager. The inspection involved: • • • Discussions with service users and staff on duty at the time. Observation of working practices and of the interaction between service users and staff members. Two service users were identified for close examination by reading their, care plans, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’ where evidence is matched to outcomes for service users. A tour of the environment was undertaken, and home records were sampled, including staff training, health and safety, and quality assurance records. Finally, feedback took place with the Manager about the inspection findings. • • I would like to thank all service users and staff for their hospitality and cooperation during the inspection visits. What the service does well: The service continues to provide a warm, friendly home of exceptionally high environmental standards, where six people with varying needs and skills live together and are cared for in a very positive way by a dedicated, motivated and well organised staff team. All information gathered during the visit demonstrated that the ethos of the home is to achieve positive outcomes for people, which include ensuring that Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 6 the facilities, staffing and lifestyle meets the diverse needs of the people living there. Central to the home’s aims and objectives is the promotion of people’s right to live an ordinary and meaningful life both in the home in the community in which they live. Mealtimes are flexible and relaxed, staff are patient and helpful and allow people the time they need to finish their meal comfortably. A relative who responded to the questionnaire sent to them made the following comment, ‘I am delighted with all aspects of the care my relative receives at Friary Road. He is very contented and happy in his surroundings.’ During the visit service users were asked what they liked best about living in the home and they made the following comments. “I have settled in well, I like it here” “I like all the staff they take us out bowling and to the pub. Last night we ate out.” “We all get on with each other”. “I think the house is very nice”. 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. The summary of this inspection report can be made available in other formats on request. Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. New people coming to live in this home can be confident that their needs are assessed and reviewed in a manner that is relevant to them, and that they will be fully involved in the process. EVIDENCE: The service is to be commended for their excellent service user guide available in written and photograph format and therefore meaningful to the needs of the people living there. The guide includes photographs about the local community and services people can access, for example, a photograph of the GP surgery and local shops. Since the last inspection a new service user has come to live in the home and their admission process was looked at during the visit. Admission records and the care plan were up-to-date and demonstrated that assessed needs were being reviewed regularly as the person settled into their new environment. The documentation showed that the service user, their family members and placing authority had been involved in the admission of the service user The service user told us that they had settled well into the home and they liked it there. They said that the house was “very nice” and that they ‘got on’ with all the people living there. Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 9 The people whose care plans were looked at each had a copy of an up-to-date contract, which had been signed by them. Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people living in this home can be confident that their needs and wishes will be met and that they will be fully consulted and kept informed concerning the ways in which this is done. EVIDENCE: The care plans for two people were looked at and this included their risk assessment information and review documentation. Each care plan looked at had clear written guidelines for staff to follow to meet specific needs, this included keeping people safe from harm in their environment and activities, communication and significant behaviours. The daily routines for each person were very detailed and included the specific times preferred for their daily activities, for example times for getting up and times for going to bed. Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 11 Risk to any activity had been assessed and guidelines put in place to ensure the activity remained safe and the service user had been able to sign that this had been explained to them. Risk strategies had been developed with the support of psychologists that may have placed the service user, or others, at risk of harm. A service user explained to us their understanding of the specific information being written and recorded about them and said that although they were not always happy about some of the information recorded, they knew why it was recorded and that, only staff would read it. Staff spoken with demonstrated a clear understanding of the individual needs of the people living in the home and said that the guidance they were given on care plans was sufficient to enable them to meet specific needs. People told us they felt safe living in the home and demonstrated a good understanding of the risks to them in their environment. For example one person said, I use the normal iron at home, the big steam iron is not safe for me to use. Team meeting records were looked at and showed that staff have opportunity to discuss care planning and working with people at their meetings and this is ensuring consistency of care practices with people. One person chose to show us their care plan records themselves and this included their Dream Book, of which they were very proud. The Dream Book contained the identified wishes, or dreams, of the service user, which they hope to achieve with support from staff working in the home. As the wish was achieved or experienced this had been documented in writing with photographs of the event and entered into the dream book. In the past 12 months the service user had achieved his wish to go to the Liverpool Football Club Stadium, cook a Sunday lunch for everybody, start a new college course and ride a motorbike. The service user said that they had planned their achievements with their key worker. Discussion with people during the visit confirmed that the home continues to support them to make decisions regarding their everyday lives. These include meals provided, activities pursued, holidays and choice of personal clothing. People said they had opportunity to talk with the provider about life in the home. They said they have a copy of the minutes of the meeting and talk about what has been done since the last meeting. They said if youve got something on your mind shell, (the provider), sort it out. People said they are asked what choices of food they would like and said that if they were not happy they knew whom they home could talk to. Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people living in this home have excellent support to live ordinary and meaningful lives and to participate in and contribute to the community in which they live. EVIDENCE: The activity diaries and lifestyle records of the two people whose care was being looked at were read with their permission. This determined that activities for people are varied and regular and support a meaningful lifestyle. People spoke about the activities they enjoyed and this included their holidays away from the home, working in local cafeteria, attending college courses, their day services, shopping, eating out and being involved in activities around the home such as cleaning, cooking and gardening. Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 13 At the time of the visit people were eagerly planning a trip to the bowling alley and other activities they wished to do whilst their day services were closed during the Whitsun holiday week. People made the following individual comments about some of their activities; ‘ At college I am learning about car valleting’ (They were happy to show us photographs of them doing this at college.) ‘I work on the garden team, we are all going out for a meal next week’. ‘I am going on holiday with my Nan and also everyone here later’. One person told us about entering a local art competition and being very proud that their entry had won first prize. People said that they liked living together and got on well and this was evident during the visit. People said that they go on regular holidays and they were very excited about the planned holiday for this year. They talked about the friend who lived locally who was going to join them for the holiday and about learning makaton sign language so that they could communicate better with the person during the holiday. This is good practice and the staff team are to be commended for this. Staff spoken with felt that providing enjoyable activities that met people’s needs and choices was one of the things that they did well. They said that it was satisfying to know that they were supporting people to meet their needs and dreams. People talked about relationships they have both with family members and in the wider community. They seemed particularly pleased with the friendships they had within the local church and talked about functions they had recently attended at the church and were looking forward to those planned for in July. People told us that they had been involved in the recent local elections, they said we did a postal vote and that staff had explained about the voting process to them. People were all complimentary about the food provision in the home and said that this was one of the things they liked best about living there. One person was very involved in their Healthy Eating Plan, which was being implemented through their day service and promoted by the staff team at the home. The service user was overheard talking about food options with the staff on duty at the time and appeared very informed about health food choices and being able to make decisions when planning their meals. Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 14 People talked about the way their food is cooked and said that cooking vegetables in the steamer, is a good idea. People talked about their role and responsibility in food preparation and one person said; I do the potatoes at home, we are having salmon, new potatoes and salad tonight but some of us are having vegetables. Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people living in this home can be sure that the health and personal care they receive is based on their individual needs and that the principles of respect, dignity and privacy are put into practice when care is offered to them . EVIDENCE: Examination of care plans and discussion with staff found that the personal care needs of people continues to be offered to them according to their needs and that the staff have a good knowledge of how people wish their care to be supported. Care practices observed during the visit were sensitive and respectful and people appeared satisfied with their care received. People who had responded to the questionnaires sent to them about life in the home said that staff always treated them well and listened and acted on what they said. Care plans looked at show that during the assessment process people are asked about their gender preference and any decisions being made about their health-care and medicine management. Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 16 The service has until recently been staffed by an all female staff team and this has always been satisfactory to the service users. Recently however a male carer has been appointed and the manager said that feedback from service users about this appointment has been positive. There is significant evidence that the advice has been sought in care planning from, learning disability nurses and behavioural therapists. Staff spoken with demonstrated a clear understanding about the specific and individual needs of the people living in the home. They said that guidelines on care plans were very clear and sufficient to enable them to manage difficult situations appropriately and safely. They said training had given them the skills to ‘defuse’ situations and support service users positively. They said that any difficult situation is followed up as a staff team and they look at their practices to see how they can work together so that care continues to be consistent. There was significant information on care plans to show that individual and specific needs of the people living in the home are discussed with and monitored by psychology services and learning disability nurses. Medicine management in this home is to a good standard with evidence that competencies of staff when administering medicine to people are regularly monitored. All records relating to medicine management seen on this occasion were up to date and care plans clearly identified the preferred way of the service user when taking their medicine. All staff receive training in the administration of medicines prior to their being able to do this in the home. Protocols were in place for all medicine to be administered when required and these had been agreed with psychologists, GPs or learning disability nurses. The manager was keen to introduce a system were protocols for administration of medicine to be administered when required were close at hand in the event of an emergency, i.e. in the medicine cabinet. Service user spoken with were familiar with the names of their GP and the medicine that they had been prescribed. Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use this service are able to express their concerns, have access to a robust, effective complaints procedure, and are protected from abuse and have their rights protected. EVIDENCE: Discussion with people using the service and staff and examination of the complaints record for the home demonstrates that there continues to be an open and positive approach regarding the service at Friary Road. People living in the home said they felt safe in their environment and with the people who were caring for them. The complaints record for the home confirmed that they have been no complaints made about the service since the last inspection and relatives comments on the returned questionnaire indicated they were aware of the home’s complaints procedure. Information for people about how to complain if they are unhappy is available to them in symbol and written format. The manager is keen to ensure that people have up-to-date information about whom they can complain to if they are not happy or satisfied with the service. This includes ensuring that information about the commission is current, i.e. telephone numbers and addresses of local offices. Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 18 There are policies and procedures in place regarding protecting people from abuse and possible harm; the most positive safeguard however continues to be the ethos and atmosphere apparent in the home. Training information looked out indicates that staff received training in abuse during 2006 and that this is planned for again in 2007. The company has a clear and appropriate policy concerning the management of service user’s finances. People spoken with said that they always had money when they needed it and demonstrated an understanding of how their money was managed by the service and were knowledgeable of how much savings they had in their bank account. Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people living in this home have a living environment that is appropriate for their particular lifestyle needs and is homely, clean, safe and comfortable and well maintained. EVIDENCE: There is a warm and welcoming atmosphere in the home and at the time of the visit it was homely, comfortable and safe. People who use the service are encouraged to see the home as their own and are able to move around easily and freely and to go to their bedroom if they wish. People were happy for their bedrooms to be looked at. They talked about where they used to live and all about their family members and interests and photographs displayed around the bedroom reflected this. The people living in the home took great pride in showing us around their home and were comfortable in doing so. They were pleased with the new Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 20 flooring in bedrooms and talked about their own responsibilities in keeping the home and gardens clean, neat and tidy. Decor, furnishings and fittings were all clean and to a high standard and the home smelt fresh and pleasant. There are established policies and procedures in place for the control of the risk of infection in the home and staff practices during the visit were seen to be safe. Infection control training is included in mandatory training for all staff and when being assessed towards NVQ Level 2. Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people who live in this home are supported by an effective and competent staff team who have the skills and knowledge to meet people’s individual and collective needs, which promotes their health and well being. EVIDENCE: The recruitment files for newly appointed staff were looked at and demonstrated appropriate and safe recruitment procedures occurred. This included confirming satisfactory Criminal Record Bureau checks and obtaining two references, one of which is from the employee’s previous employer. Provider information looked at prior to the visit to the home demonstrated that there is a comprehensive training programme in place for staff which includes safe working practices, care of medicines, person centered planning, protection of vulnerable people, Learning Disability Award Framework, (LDAF), Induction and training in the specific needs of the people living in the home, which includes Downs Syndrome, autism and makaton. A staff member spoken with said that training was regular and there was always refresher courses available, such as food hygiene and infection Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 22 control. They said that makaton training was being provided for staff and service users so that it could be used on holiday with a friend of service users who was joining them for a holiday this year. There is a rolling programme of assessment of care staff towards an NVQ Level 2 or above and 80 of the staff team have achieved this award. Polesworth Group Homes have a designated training and development officer for their services. Observation of care practice and discussion with staff on duty at the time determined that positive relationships exist between service users and the staff supporting them. Staff were seen to be approachable by, and comfortable with service users, they were good listeners and communicators, and were interested and committed to the work they were doing. Staff were complimentary about the support from the manager and said that they were able to discuss service issues at supervision and staff meetings. Service users spoken with said that they liked the staff and had particular regard for their individual key workers. They said that staff took them out regularly and gave some examples such as, bowling, having meals out and going shopping. Information received from relatives questionnaires indicated that staff always welcomed them into the home when they visited and that there were generally sufficient numbers of staff on duty. There is a low staff turnover with many staff having worked at Friary Road for a number of years. In the event of a staff member leaving the service the manager conducts an exit interview and assess the outcome as part of quality assurance processes and service improvement. Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people living in this home continue to benefit from a well run home that has effective systems in place to ensure their health and well-being is promoted and maintained. EVIDENCE: Discussion with service users, staff and the manager, examination of home records and observation of care practices demonstrated that the service is managed by a competent and skilled manager who fosters an atmosphere of openness and respect with service users, and that staff feel valued and their opinions matter. The manager has successfully completed the Registered Managers Award and said that they will forward a copy of the Certificate of Accreditation to the commission when she receives it. Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 24 Service users had a high regard for the manager and a positive, friendly relationship between them was observed. Staff spoken with said that the manager was, fair, listened and took on board what people were saying. There are affective quality assurance and monitoring processes in place to ensure the home is meeting the needs of the people living there. Quality monitoring covers all areas of the service and includes, training and development of staff, food provision, staffing levels and complaints. Quality assurance records looked at show that the service has a commitment towards involving people using the service, relatives and friends, health-care professionals and staff through seeking their views by questionnaire or consultation meetings. There is evidence to show that service users are involved in recruitment of staff, planning daily menus and activities through their six monthly individual review meetings, quality house meetings with the chief executive of Polesworth Group Home and an annual questionnaire. Family carers are consulted with at annual carers meetings and through an annual postal questionnaire. During discussion with her the manager demonstrated a clear understanding of the key principle of seeking the views of the people who use the service as part of future development of the service and ensuring that equality and diversity issues are given priority. People said that they regularly meet with the provider of the service to discuss issues in the home. They said, we talk about what weve done and we have minutes of the last meeting. If you have something on your mind you are able to talk about it and she, (the provider), will sort it out. Health and safety management in this home is to a high standard and all records seen relating to this were up-to-date and in good order. Safe practices were observed in the home and records show that this is further promoted through training for staff in manual handling, food hygiene, first aid, fire safety and infection control. Pre-inspection information received shows that maintenance of fire fighting equipment, electrical appliances and central heating systems takes place on a regular basis. Excellent systems are in place for ensuring that food hygiene is maintained and monitored, this includes recording fridge and freezer temperatures and cooked meats. Fire safety management includes regular testing of fire alarms and emergency lighting and all records relating to fire safety management were up-to-date and in good order. Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 25 A record is maintained in the home of any accident or incident that happens to a person using the service. All records seen during this visit were stored securely and in good order. Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 26 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 4 2 4 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 4 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 x 4 X 4 X X 4 x Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard YA22 YA20 Good Practice Recommendations Information available to service users about how they can contact the commission should be up to date. Medicine to be administered when required should be close at hand in event of an emergency, i.e. in the medicine cabinet. Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Polesworth Group Friary Road DS0000004281.V336391.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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