Inspection on 23/05/07 for Polesworth Group Pooley Heights

This inspection was carried out on 23rd 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 Pooley Heights 07/05/09

Polesworth Group Pooley Heights 27/10/05

Polesworth Group Pooley Heights 20/06/05

Polesworth Group Pooley Heights 31/01/05

Polesworth Group Pooley Heights 22/07/04

Polesworth Group Pooley Heights 16/03/04

Similar services:

Polesworth Group Friary Road

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 Pooley Heights Pooley Heights Pooley Lane Polesworth Staffordshire B78 1JA Lead Inspector Sheila Briddick Key Unannounced Inspection 23rd May 2007 09:30 Polesworth Group Pooley Heights DS0000004282.V340939.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 Pooley Heights DS0000004282.V340939.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 Pooley Heights DS0000004282.V340939.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Polesworth Group Pooley Heights Address Pooley Heights Pooley Lane Polesworth Staffordshire B78 1JA 01827 894197 01827 892500 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Polesworth Group Homes Limited Mrs Leigh-Anne Smith Care Home 6 Category(ies) of Learning disability (6), Physical disability (1) registration, with number of places Polesworth Group Pooley Heights DS0000004282.V340939.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Leigh Anne Smith (Registered Manager) must obtain the Registered Managers Award by 30th July 2007. 27th October 2005 Date of last inspection Brief Description of the Service: Pooley Heights is part of the Polesworth Group Homes Ltd. The company was established in June 1991 with the aim of providing accommodation and support to people with learning disabilities. Pooley Heights is a large, detached bungalow in a rural setting on the outskirts of the village of Polesworth near Tamworth. Many local shops and services are within walking distance. The service provides five planned short stay and one emergency care places. There are around forty service users who have regular short stays. The property has been extended to provide four single bedrooms and one double bedroom. Three single bedrooms and the double bedroom have en-suite facilities and the fifth bedroom is adjacent to a bathroom that includes corner bath, shower, toilet and basin. There is a garden backing onto open fields that has a decked area and lawns with flowerbeds. There are level walkways in the garden with wheelchair access and ramps. There is an eight seater People Carrier that provides transport for the service users and public transport also passes the end of the road. All placements at Pooley Heights are currently commissioned by Warwickshire Social Services. All Block Payment fees are agreed with the appropriate Funding Authority. Polesworth Group Pooley Heights DS0000004282.V340939.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 two service user and five 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 on the same day, 23rd May 2007. The first visit took place in the morning to look at care plans and home records, and to talk with the manager and staff. A second visit was made in the late afternoon to meet with people using the respite service at that time to seek their views on the respite service provision. 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 homely environment of exceptionally good environmental standards, where six people with varying needs and skills can enjoy a respite service for varying lengths of time throughout the year and be cared for in a very positive way by a dedicated, motivated and well organised staff team. Polesworth Group Pooley Heights DS0000004282.V340939.R01.S.doc Version 5.2 Page 6 All information gathered during the visit demonstrated that the ethos of the home is to provide a valuable respite service for local people who need and benefit from such a service. It provides a friendly, well-organised service on a homely, domestic scale, in which people using the service readily feel comfortable and at ease. During the visit people were asked what they liked best about using the service and they made the following comments; I like coming here because there is no ‘bickering’ . I like helping the staff and we have a nice garden Staff are kind and caring. I feel safe here. The best thing is watching TV and going out. Additional comments made by relatives in response to the Comment Cards sent to them included; We rely on the short stay home. It has been so good that we have learnt to trust them. In our opinion the organisation is well run and the staff are helpful, very pleasant and seemingly very efficient. Pooley Heights is a delightful home, I find the staff excellent in all ways. A lovely respite home. Excellent provision - provides real peace of mind to us as carers. What has improved since the last inspection? What they could do better: A small area of a working surface in the laundry was rusting and the manager agreed that this needed repair so that cleaning in the area would promote infection control and they made immediate arrangements for the repair, which was completed before this report was published. All other areas of the environment were to an extremely high standard of repair. Polesworth Group Pooley Heights DS0000004282.V340939.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Polesworth Group Pooley Heights DS0000004282.V340939.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Polesworth Group Pooley Heights DS0000004282.V340939.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 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 choosing to use this service 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 the excellent information available to people who may wish to use the service. A service user guide is available in written and photograph format and therefore meaningful to the needs of the people who may wish to use the service. Polesworth Group Homes have also produced a video about the service, which can be viewed by prospective service user. There is a well-established admissions process for this service following a referral through the care management assessment process. The manager explained that once the referral has been made for respite service a home visit is made to the service users own living environment when the individuals and carers needs are discussed with them. Following this the person wishing to use the service can make a series of visits to the home and an assessment of needs takes place at these times to enable a care plan to be put into place for any future respite stay Polesworth Group Pooley Heights DS0000004282.V340939.R01.S.doc Version 5.2 Page 10 During the admission visits a record is made of how well the person settles in and of the relationship they do or do not develop with other people using the service at the same time and misinformation is then used when planning respite stays in the future so that people using the service at the same time a comfortable with each other which promotes their well-being during their stay. The people using the service at the time of the visit were observed to be comfortable with each other and familiar with each of us likes and dislikes. A service user told us, When I come here, I stay with people I get on with. The records of two service users were looked at during the visit and the admissions process in each instance was well documented. Polesworth Group Pooley Heights DS0000004282.V340939.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 6, 7 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people living in this home can be confident that their needs and wishes will be met and that they will be fully consulted and kept informed concerning the ways in which this is done. EVIDENCE: The care plans for two people were looked at and this included their risk assessment information and review 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 Pooley Heights DS0000004282.V340939.R01.S.doc Version 5.2 Page 12 Risk to any activity had been assessed and guidelines put in place to ensure the activity remained safe and people had been able to sign, when possible, that this had been explained to them. Risk strategies that may have placed people at risk of harm had been developed with the support of psychology services. Care plans were very clear in the preferred daily routines of people who are supported to continue their day service activities during their respite stay. One service user told us, I like being able to still go to the day centre. There is evidence that care needs are reviewed as and when needs change and this includes care management reviews and involvement with psychology reviews. 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, they said, I feel safe here” and “I can lock my door at night. During the visit staff were observed to involve the people using the service in decisions to be made about the evenings routine. One person had just arrived at the home for their respite stay and discussed the following days activity with staff and how they would get to their work placement. There is one shared bedroom facility in the home and during the admissions process people are asked if they would mind sharing a bedroom and the decision they made is respected. People were asked about this during the visit and they told us that they did not have to share a bedroom if they did not want to. People said they had choices about when they wanted to go to bed and what to eat at mealtimes, although they generally agreed the evening meal together. They said, we go to bed when we want and we have cereal, toast and coffee for breakfast if that is what we want. 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 for people during their stay. Polesworth Group Pooley Heights DS0000004282.V340939.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people using this service are able to enjoy meaningful activities in the home and local community and continue to keep to their daily routines when using the service which, promotes and supports their individual needs and well-being. EVIDENCE: Discussion with people using the service at the time and staff on duty, and looking at daily records told us that during their respite stay people are supported to continue to enjoy activities they prefer during their stay and experience activities in and around the community where the respite service is situated. After tea, people were going to go for a walk in the local village, Polesworth. Staff working in the home live locally and have a good knowledge of the local facilities available, i.e. a local mining history Museum, cafes, restaurants and shops. Polesworth Group Pooley Heights DS0000004282.V340939.R01.S.doc Version 5.2 Page 14 As previously said in this report people using the service are able to continue with their day activities during their respite stay and this is something people say they particularly like about the service. Staff were keen to ensure that people were confident that their day activities would happen and they were overheard reassuring a person that they would be able to attend their work placement during their stay. They did this sensitively, giving clear explanation of how the person would be able to get there and agreeing with the person the times that this would happen. 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, We give people opportunity to go out and mix with other people but also we give 1 to 1 time to people. During their stay people can maintain contact with their family members if they wish to. One person told us, I phoned home today to see if Mom was okay. A good variety of wholesome food continues to be available and individual needs are catered for. People told us that they liked the food and could have a choice if they wished. People using the service are encouraged to participate in meal preparation, shopping for food and preparing the table for the meal. Polesworth Group Pooley Heights DS0000004282.V340939.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 using this service 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. 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. Polesworth Group Pooley Heights DS0000004282.V340939.R01.S.doc Version 5.2 Page 16 Staff demonstrated a good understanding of the emotional needs of people who were away from family and friends during a respite stay and were observed to support people sensitively and calmly when this was necessary. 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 medication received into the home when a person begins the respites day is double checked by two staff and this includes any changes of prescription by the service user’s general practitioner. All medication has to be received in prescribed packaging and there is the process for completing an Alert Form for any change in previous medication so all staff are aware of the change. All staff receive training in the administration of medicines prior to their being able to do this in the home. Polesworth Group Pooley Heights DS0000004282.V340939.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 feel they 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 demonstrated 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 the environment and with the people who were caring for them. People said they are able to lock their bedroom at night if they wanted to and knew whom they could speak to if they were not happy. One person made an additional comment on their questionnaire sent to them saying, Leigh-Anne, (the manager), is always happy to listen to people of all ages. 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 easily available to them in symbol and written format. Polesworth Group Pooley Heights DS0000004282.V340939.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 using the respite service can bring in small amounts of money for spending during their stay and records are maintained of these expenditures. Polesworth Group Pooley Heights DS0000004282.V340939.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, 25 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people using this service can enjoy accommodation during their respite stay 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 house 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 during their time there and are able to move around easily and freely and to go to their bedroom if they wish. The people using the service at the time took great pride in showing us around the house and were comfortable in doing so. They told us that they liked their bedrooms and could lock their bedroom door, cupboards and wardrobes if they wanted to. People are encouraged to bring in their own things during their respite stay and had done so. There is a shared bedroom facility and only people who wish to use this do so. Each service user met with said that they did not have to share the bedroom if they didnt want to. Polesworth Group Pooley Heights DS0000004282.V340939.R01.S.doc Version 5.2 Page 20 Decor, furnishings and fittings were clean and to a high standard and the home smelt fresh and pleasant. There is a pleasant garden, with outdoor seating facilities. People said that they eat outside when the weather is nice and one person said that the garden is one of the things they liked best about the house. 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. A small area of a working surface in the laundry area found to be ‘rusting’ and in general poor condition. The manager agreed that this could present a small risk in infection control and immediately took steps for the arrangement of the repair to the surface. Polesworth Group Pooley Heights DS0000004282.V340939.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 use this service 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 that appropriate and safe recruitment procedures took place. This included confirming satisfactory Criminal Record Bureau checks and obtaining two references, one of which was 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 and Learning Disability Award Framework, (LDAF), Induction. Staff are also accessing training in the specific needs of the people living in the home, which includes Epilepsy, Downs Syndrome, autism and Loss and Bereavement. Polesworth Group Pooley Heights DS0000004282.V340939.R01.S.doc Version 5.2 Page 22 Staff coming to work in the service complete the Skills for Care Council’s common induction standards. New staff working in the home were complimentary about their training during the induction process. A staff member spoken with said that training was fantastic, they had undertaken training in vulnerable adults, had achieved an NVQ at Level 2 and were looking forward to starting their NVQ Level 3. There is a rolling programme of assessment of care staff towards an NVQ Level 2 or above and 75 of the staff team have achieved this award, which is commendable. 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. Service users spoken with said that staff were nice and were very kind and caring. Information received from relative’s questionnaires indicated that staff always made them feel welcome and that there were always sufficient numbers of staff on duty. There is a low staff turnover with many staff having worked at Pooley Heights 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. Staff spoken with said that they had regular team meetings when they were asked for their views and able to discuss care issues. During discussion with them staff demonstrated an understanding of the needs of the people who were using the service at the time they also said that they have opportunity to access care plans to ensure that they remained knowledgeable about current needs of people using the service. Staff said they felt that guidance on care plans was good’ and that they had opportunity to discuss any questions or concerns they may have during ‘handover’ of shifts or their supervision. Polesworth Group Pooley Heights DS0000004282.V340939.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): Standard 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 using this service 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 during their time there. 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 she will forward a copy of the Certificate of Accreditation to the commission when she receives it. Polesworth Group Pooley Heights DS0000004282.V340939.R01.S.doc Version 5.2 Page 24 There are effective quality assurance and monitoring systems in place to ensure the home is meeting the needs of the people using the service. 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 planning daily menus and activities through their individual review meetings, 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, and staff, as part of future development of the service and ensuring that equality and diversity issues are given priority. 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 working 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. 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 Pooley Heights DS0000004282.V340939.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 4 26 X 27 X 28 X 29 X 30 3 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 N/A 4 X 4 X X 4 x Polesworth Group Pooley Heights DS0000004282.V340939.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Polesworth Group Pooley Heights DS0000004282.V340939.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Local Office 1st Floor, Ladywood house Stephenson Street Birmingham West Midlands 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 Pooley Heights DS0000004282.V340939.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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