CARE HOME ADULTS 18-65
Polesworth Group - 19 Pooley View 19 Pooley View Polesworth Tamworth, Staffordshire B78 1BN Lead Inspector
Catherine Mundy Unannounced 17 August 2005 15:30 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 - 19 Pooley View E53 S4450 Polesworth Group 19 Pooley View V245402 170805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Polesworth Group - 19 Pooley View Address 19 Pooley View Polesworth Tamworth Staffordshire B78 1BN 01827 896124 01827 892500 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 Limited Ms Sue Black Care Home 4 Category(ies) of Learning Disability (4) registration, with number of places Polesworth Group - 19 Pooley View E53 S4450 Polesworth Group 19 Pooley View V245402 170805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 1 March 2005 Brief Description of the Service: 19 Pooley View is a care home registered to provide care for up to four people who have a learning disability. It is managed by Polesworth Group Homes Limited. The home is a modern house situated in the village of Polesworth, close to all village amenities. It has five bedrooms (one is used as a sleep in/office for staff). There is a bathroom on the first floor and the ground floor bedroom has en-suite facilities. There are two WCs upstairs and an additional shower facility. There is a rear garden, which that leads onto open fields. Polesworth Group - 19 Pooley View E53 S4450 Polesworth Group 19 Pooley View V245402 170805 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 17th August 2005 between the hours of 3.30 pm and 7 pm. During this time the inspector had the opportunity to meet with the residents, observe the interactions between the residents, staff and their environment, tour the home and examine documents relating to the residents and the management of the home. One staff member and the Registered Manager were also involved in the inspection process. What the service does well:
The feedback received from the residents was 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 philosophy of the home is to promote and maintain the residents independence. The residents are enabled to contribute to the day-to-day running of the home, and share responsibility with the staff for the completion of household chores. The residents were proud of their achievements within the home and in the maintenance of the gardens, which are immaculately kept. Staff arrangements within the home are adapted to meet the needs and wishes of the residents. There are periods of the day when staff support is not provided. This allows the residents further opportunity to maintain their independence. This arrangement is appropriate for the home and reflects the wishes of the residents. Staffing support is provided, flexibly, to the home as the residents needs and wishes dictate. The home provides the residents with a clear and concise plan of care which reflects the residents personal preferences as to how their identified needs are to be met. Appropriate risk assessments have been completed. Risk management strategies have been developed to meet the risks identified. The home responds appropriately to the residents changing needs, initiating referrals to the relevant health care professionals. The residents are supported to take part in a broad range of valued and fulfilling activities, which reflect the residents preferences and personal development needs, during the day, in the evenings and at weekends. This includes college courses, employment and leisure opportunities. Polesworth Group - 19 Pooley View E53 S4450 Polesworth Group 19 Pooley View V245402 170805 Stage 4.doc Version 1.40 Page 6 The home provides information that is relevant to the residents in a format that is accessible to them. This includes the homes Service Users Guide, Contracts, detailing terms and conditions of residency, care plans, activity plans and the organisations complaints procedure. The organisation facilitates regular house meetings with the residents to ascertain their views as to the services provided in the home. These forums provide the residents with the opportunity to raise concerns or to make a complaint. The residents confirmed that they are confident that any concerns raised would be dealt with appropriately. The organisation also conducts visits to the home, under Regulation 26 of the Care Homes Regulations 2001. This provides an additional forum for the residents to give feedback regarding the home. 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 staff are provided with training, regular supervision and appraisal to enable them to fulfil their roles effectively. Training is, in the main, provided by facilitators who are external to the organisation including health care professionals and the British Institute for Learning Disabilities (BILD). 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 - 19 Pooley View E53 S4450 Polesworth Group 19 Pooley View V245402 170805 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 - 19 Pooley View E53 S4450 Polesworth Group 19 Pooley View V245402 170805 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 and 5 The residents are provided with sufficient information, in a format that is accessible to them, which details the services provided in the home. EVIDENCE: The home has a Statement of Purpose, which is subject to regular review. This details the services that are provided in the home. A copy if this document is available in the homes office. It is advised that this will be made available to prospective residents. The home has also provided each of the residents with a Service Users Guide to the home and contracts detailing terms and conditions of residency with in the home. These documents are produced in a format that is accessible to the residents, using pictures, symbols and appropriate language. These documents are held by the residents and are stored within their own bedrooms. There have been no new admissions to the home since the time of the last inspection; standards 2, 3 and 4 were therefore not inspected on this occasion. These standards have been met at previous inspections of this home. Polesworth Group - 19 Pooley View E53 S4450 Polesworth Group 19 Pooley View V245402 170805 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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 and wishes. EVIDENCE: The residents are provided with a clear and concise plan of care, which details the actions to be taken by the home, to meet the residents identified needs and wishes. These are produced in a written format for the staff. A copy has been provided to the resident to whom it refers, this is provided in a format that is more accessible to the resident using pictures, symbols and appropriate language. One resident has enhanced his care plan further with the use of photographs. These documents are held by the residents and are stored in their bedrooms. There is evidence that the residents are consulted as to the content of their care plans, with formal reviews taking place twice yearly. Polesworth Group - 19 Pooley View E53 S4450 Polesworth Group 19 Pooley View V245402 170805 Stage 4.doc Version 1.40 Page 10 Risk assessments have been completed and risk management strategies developed to meet the risks identified. The format in which these are provided has recently changed to enable easier accessibility for the staff. Risk assessments and risk management strategies are also subject to regular review. The home should consider formalising the risk assessment that is in place with regard to the residents spending time alone within the home. Polesworth Group - 19 Pooley View E53 S4450 Polesworth Group 19 Pooley View V245402 170805 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) 11, 12, 14 and 17 The residents are supported to take part in valued and fulfilling activities which promote and maintain their independence and that they enjoy. The residents enjoy the meals that are provided by the home. The home offers a varied and balanced diet which reflects the residents choice. EVIDENCE: The residents are supported to take part in valued and fulfilling activities during the day, in the evenings and at weekends. Two of the residents are employed, on a part time basis, one by the local Co-op and another by Mealson Wheels. The other two residents access a structured day placement. The residents have also had the opportunity to attended college courses and take part in leisure activities, these included parties, concerts, cinema, meals out and visits to the local pub. The residents advised that they like to spend time relaxing at home in the evenings. On the day of the inspection the residents were observed to spend time knitting, watching television and assisting with household chores.
Polesworth Group - 19 Pooley View E53 S4450 Polesworth Group 19 Pooley View V245402 170805 Stage 4.doc Version 1.40 Page 12 One of the residents confirmed that the home has supported her to maintain links with her family, by telephone twice each week and by regular visits. The residents are supported to promote and maintain their independence. There are periods of time during the day and at the weekend when the home is not staffed. The staffing rota is developed to reflect the needs of the residents, this enables the residents to have some time alone in the home whilst maintaining higher levels of support required at other times of the day. The residents are responsible for the completion of some household chores; this is detailed in their terms and conditions of residency within the home. Each resident has a timetable, provided in a pictorial format to remind them of their chores. It is apparent that the residents and staff contribute equally to the running of the home. The menus available in the home confirmed that the residents have been provided with a healthy, nutritional diet. The residents choose meals, each evening for the following day. The residents confirmed that an alternative meal is provided if requested. Ample food stocks were available to support this. One resident prepares his own packed lunch, the residents also assist with food shopping; providing additional opportunities for the residents to choose their meals. The residents confirmed that they enjoyed the meals that are provided Polesworth Group - 19 Pooley View E53 S4450 Polesworth Group 19 Pooley View V245402 170805 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 and health care needs are met in a manner which reflects their personal choice, and promotes their privacy, dignity and independence. 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 documented in their individual plans of care. These reflected that the residents privacy, dignity and independence are respected. The interactions between the residents and staff confirmed this. The care plans also detail the residents health care needs. A record is maintained of all contact with healthcare professionals and of any issue which may affect the residents health. The outcome for the resident is also recorded. There is evidence that the home has appropriately supported one of the residents though a period of ill health. This has included involvement of relevant healthcare professionals. There is also evidence that the residents are supported to access routine screening at the GP surgery, opticians and dentists. A chiropodist visits the home. It is advised that the home is in the process of completing Health Action Plans, with the support of the Primary Care Trust, for each of the residents. The residents needs are such that the home maintains responsibility for the management of the residents medication. The procedures in place continue to reflect good practice.
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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 a satisfactory complaints procedure in place, the residents are confident that any concerns they raise will be listened to and acted upon. The homes policies and procedures protect the residents 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 to resolve any issues raised or complaints made. The complaints log confirmed that there have been no complaints made since the time of the last inspection. The complaints procedure is provided in a format that is accessible to the residents, this is displayed in the hallway. The organisation also facilitates regular meetings, which provide the residents with the opportunity to raise a concern. The residents confirmed that they were aware of the procedure to follow should they wish to make a complaint; they confirmed that they were confident that any issues raised would be addressed appropriately. The residents confirmed that they are happy with the care that is provided in the home. The organisation has an adult protection and whistle blowing procedure in place. These are available in the home. The organisation has also developed a policy which reflects the Department of Health guidance relating to the Protection Of Vulnerable Adults (POVA). The manager demonstrated through discussions that appropriate action would be taken in the event of suspected abuse, all of the staff working in the home have received training relating to this. The financial records relating to one residents 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 and 30 The standard of the environment is good, providing the residents with a comfortable and homely place to live, the homes philosophy of shared responsibility enables the residents to play a valued role in maintaining the home. EVIDENCE: The home is well maintained, comfortable and homely. The décor and furnishings are of good quality, reflecting the preferences and personalities of the residents residing in the home. Each of the residents have their own bedrooms, one bedroom has an ensuite bathroom. Three residents share the bathroom, which is located on the first floor of the home. Communal space within the home includes a dining kitchen and an open plan lounge and dining room. There is also an office/sleep-in room for the staff. Responsibility for maintaining the cleanliness of the home is shared by the staff and residents. On the day of the inspection the home was clean and tidy. The residents immaculately maintain the front and rear gardens. They were proud of their achievements. Laundry facilities are appropriate for the needs of the home.
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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) 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 three staff members, on a permanent basis, and two staff members on an adhoc arrangement. All of the staff have been employed in the home 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, there are also periods of the day in which the residents spend time alone within the home. This is dependent upon the needs of the residents. The home provides a sleep-in member of staff for support in the night. These staffing ratios are appropriate for the needs of the residents. 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. This is within walking distance of the home. The Registered Manager advised that she visits the home on a daily basis, or as the needs of the service dictate. This level of support is appropriate for the needs of the home.
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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) 38 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. EVIDENCE: The Registered Manager demonstrated her competency to fulfil her role effectively throughout this inspection. 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, the completion of risk assessments and provision of risk management strategies. The certificate to confirm that portable electrical appliances have been safety checked, was not available in the home.
Polesworth Group - 19 Pooley View E53 S4450 Polesworth Group 19 Pooley View V245402 170805 Stage 4.doc Version 1.40 Page 18 The Registered Manager assured the inspector that this would be forwarded to the Commission for Social Care Inspection following the inspection. 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 not currently fitted with thermostatic controls which will reduce the risk of scalding. The Registered Manager advised that there is a plan in place to address this. The home should ensure that the water temperatures are monitored and recorded. Polesworth Group - 19 Pooley View E53 S4450 Polesworth Group 19 Pooley View V245402 170805 Stage 4.doc Version 1.40 Page 19 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 x x x 3 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 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 3 3 x 3 x x x Standard No 31 32 33 34 35 36 Score x x x x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Polesworth Group - 19 Pooley View Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x 3 x x x 3 x E53 S4450 Polesworth Group 19 Pooley View V245402 170805 Stage 4.doc Version 1.40 Page 20 N/A 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 Regulation Requirement No requirements have been made. 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 9 42 Good Practice Recommendations The home should formalise the risk assessment, and develop risk management strategies, relating to the residents spending time alone within the home. The home should continue with the plan in place to provide thermostatic controls to hot water outlets, and commence monitoring of water temperatures. Polesworth Group - 19 Pooley View E53 S4450 Polesworth Group 19 Pooley View V245402 170805 Stage 4.doc Version 1.40 Page 21 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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