Inspection on 02/06/05 for Polsloe House Ltd

This inspection was carried out on 2nd June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Polsloe House Ltd 29/08/06

Polsloe House Ltd 07/11/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Polsloe House 22 Park Road Redruth Cornwall TR15 2JG Lead Inspector Stephen Baber Announced 02 June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Polsloe House Address 22 Park Road Redruth TR15 2JG 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) 01209 215337 Polsloe House Ltd Mary Butland Care Home 13 Category(ies) of Dementia - over 65 years of age (2), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (2), Old age, not falling within any other category (13) Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Posloe Ltd is registered under The Care Standards Act 2000 and Care Homes Regulations to provide personal care and accommodation to 13 elderly residents.The categories also extend to registration for 2 people who have Dementia (D.E) or mental disorder (M.D.E.) over 65 years of age other than a learning disability. Date of last inspection 4th November 2005 Brief Description of the Service: Polsloe House is a detached building set in its own grounds, which the residents said they enjoy especially in the better weather. It is situated near to the town of Redruth with all its services and facilities accessible to the home. Polsloe is close to local General Practitioners surgeries with Camborne and Redruth Hospital one and a half miles away. The registered providers Mr and Mrs Butland are newly registered; previously Mrs Butland was the registered manager. There are 11 single rooms and one double room. Three of the rooms have ensuite facilities. Polsloe offers full personal care and residential accommodation to older people, including up to two people with dementia or with other mental health needs. Management describes the aims, services and facilities clearly in the Statement of Purpose and Service user guide. The home sets out to provide a high quality service that responds to individual needs and preferences. Management are generally able to take their residents to hospital and medical appointments or appropriate arrangements are arranged. Polsloe has a stable group of mature staff that have worked at the home for some time offering continuity of service. All the service users and relatives visiting were consulted and they gave the inspector very good feedback on the care and comfort they receive from management and staff. Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection as part of the home’s annual inspection programme on 2nd June 2005 starting at 9.00 am and finishing at 16:30 p.m. The inspector was at the home for seven and half hours The inspection took place over one weekday. The inspector undertook the following activities whilst at the home 1. Inspection of records, including assessment information and care plans 2. Discussion with the manager of the home on how it operates on a day-today basis 3. Inspection of the building 4. Interview with 4 members of staff and discussion the manager. 5. Individual interviews with each of the 10 residents. 6. Observation of the daily life of the home. 7.One relative was present on the day of the inspection. The registered manager was very well prepared for the inspection, which was facilitated by the full cooperation of the residents and staff. This is the first inspection of Polsloe under new ownership. Previously Mrs Butland was the manager of the home. The inspection report shows that the management have done a lot of work to improving the record keeping, policies and procedures and investing significantly in making improvements in the home. Information material has been prepared and was well presented. Residents reported that they felt comfortable and well care for. The statement of purpose and service users guide set out the homes objectives in relation to privacy and dignity. Residents said that staff were supportive and caring towards them. Some policies and procedures require fine turning to make them fully comply with the national minimum standards and staff require training in adult protection. Formal supervision and staff appraisal of staff has been introduced and the quality assurance exercise was impressive in its presentation with positive outcomes for residents. The manager completed a pre-inspection questionnaire, which was received by me before the inspection. What the service does well: One of the benefits of taking over as the new owner is having worked as the manager previously. This gives security to residents and staff. Prospective residents are provided with the opportunity to visit the care home as part of Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 6 their decision making process. Each prospective resident is also provided with written information about the care home to assist him or her in making a decision about where they wish to live. Residents are positive about the manner in which staff treats them and this has a very reassuring effect on the continued well-being of the residents. As evidenced from the records any concern about a resident’s health is dealt with promptly and arrangements are in place to make sure all a resident’s health needs are met. Improvements have been made for the safe-keeping and administration of medicines. The residents said that they can choose what they want to eat at all meal times and the meal on the day was wholesome and nutritious. There is a free house when it comes to visiting and the visitors are made welcome with a tray of tea Residents said they were very satisfied with the standard of hygiene and cleanliness and the care home is being significantly improved since new providers have taken over. Another positive feature of the home is that the staff have been there for several years and they offer security and continuity of care. Training for all staff is also a strong feature of the home as evidenced from staff records. Experienced staff are on duty each day and there are two staff on waking night duty every night. What has improved since the last inspection? What they could do better: Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 7 I talked with the manager about what she thought could be done better. Whilst entertainers and some activities are arranged she would like to see more activities based on individual choice and preference. The policies and procedures could be further expanded to include more information for staff. Care Plan arrangements also require improvement with actions and outcomes recorded. This will assist the staff in meeting the residents’ needs in the manner of their choice and preference. The adult protection policy and procedure and this needs to reflect the Department of Health’s Guidance ‘No Secrets’ and role of the multi agency disciplinary teams particularly social services and (procedure 77). This will inform, direct and guide staff on what steps to take if any concerns arise. 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. Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,4,6. Residents and prospective residents recive information about the home and the services provided. The care home has written information about the facilities and services provided. Prospective residents are given a copy of the information to help them make an informed choice about the care home. Prospective residents are also able to visit the care home as part of the decision making process. Needs assessments for each resident are recorded before they move into the home, in order to make a decision as to whether the home can meet their needs. EVIDENCE: The statement of purpose and the service users guide are complete documents and as well as being on display in the entrance hall are available to residents and prospective residents. Detailed assessments have been recorded for all residents. There are risk assessments on each resident but these must be further developed to include an environmental risk assessment to safeguard and promote the residents. The most recent admission felt that her admission had gone smoothly and that she was settling in well. Her daughter who visited that day also confirmed this. Intermediate care is not provided. Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 10 Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10. Care plans set out the basic health and personal care needs of the residents, but need further development to record actions and outcomes achieved. Risk assessments for residents and moving and handling are completed. These need to include environmental risk assessments so that residents can be safe and staff are aware of what they can achieve. Policies and procedures on the safe handling of medication are made available to all staff to protect residents. An audit trail of resident’s records must take place with outcomes and actions taken to further improve the services and the safety of residents. EVIDENCE: All residents have a care plan. The care plans in place must have an audit trail with actions taken and outcomes achieved. This was not the case on the day of the inspection. The residents said that the care provided is to a good standard and nothing is too much trouble for the staff. Residents said they were satisfied with the care and support and assistance provided by the staff. The arrangements in place to minimise risks to residents also need to be improved to protect them. This was discussed with the manager and a way forward was agreed. The environmental risk assessment would assist staff and not compromise a resident’s safety. Any action-required to minimise the assessed risks will then need to be part of the individuals care plan. The records confirm that management and staff have a positive approach to meeting the health Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 12 care needs of residents. Residents said that the doctor was called promptly when any concerns arise. The residents are also supported to access specialist medical services such as the dentist, optician and chiropodist. Comments were made by the residents on the way they are treated in a dignified and respectful manner by staff at the home. Observations made were of staff knocking at doors addressing residents by the name of their choosing and talking to residents in a positive manner. Another improvement made is in the area of medication. The manager ensures that there is a policy and procedure in place for staff to follow. Staff understood procedures for the receipt, recording, storage and disposal of medication. All staff that dispenses medication has successfully completed the safe Handling of medication training. The new storage facility for medicines was well ordered. A physical count and check of the medication system proved to be satisfactory. Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15. Social and leisure activities are organised but more work needs to be carried out to introduce activities that match individual preference and expectations of the residents.. The visiting arrangements are flexible and visitors are well received by the staff. This helps residents to keep regular links with their family and friends. There are no restrictions to residents accessing the community and local facilities when it is safe to so. Meals are nutritious and balanced and offer healthy and varied diet for the residents. EVIDENCE: All the residents were spoken to about activities. Some residents said they enjoyed entertainers coming into the home and some said that they enjoyed some activities. One resident said she enjoys reading the paper from back to front everyday, whilst one said I prefer to watch television because of my eyesight. Some residents said that they did not want to join in with any activities and was pleased that staff respected this and did not try and make them join in. Residents said there are no visiting restrictions and the staff positively welcomes any visitors. Residents decide where they meet with visitors and the staff will support them if they decide they do not wish to receive a visitor. Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 14 A number od residents said how they look forward to mealtimes and that they welcome the daily choices offered. Residents are very satisfied with the food provided and commented on the quality of the meals. Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18. Complaints are handled properly to provide residents with confidence that their concerns will be listened to, taken seriously and acted upon. The lack of a vulnerable adults full procedure and training for staff does not ensure that the residents living in the home are protected from abuse. EVIDENCE: The complaints procedure complies with the standard and there is evidence that the views of service users are regularly sought. The residents said they would know how to complain if they needed to. The policy and procedure on adult protection must be further developed to reflect the Deparment of Health’s ‘No Secrets’ and the local procedures under the protection of vulnerable adults (POVA) role of the social services. Staff must receive training in the protection of vulnerable adults to enable them to protect service users from abuse. Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26. Major improvements are underway to improve all areas of the home both internally and externally. This provides safe and comfortable surroundings in which to live EVIDENCE: The new providers have invested in improving in the home since taking over in November 2004. Rooms have been redecorated and recarpeted, hallway redecorated residents have locks on their doors, doors have been repainted, new carpets for some of the home have been fitted, radiators have been covered and thermostatic control valves have been fitted where total body immersion takes place and work is still ongoing in phases. Residents said they were very happy to see the major improvements taking place and were satisfied with the facilities provided and standard of hygiene maintained. Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30. Staffing levels generally meet the needs of service users. The recruitment processes carried out for staff protects service users. The training policies and practice develop the knowledge, skills and competence of staff in all required areas. The number of staff on duty each day and night is satisfactory to meets the needs of the residents. The staff at the care home all has a lot of experience of providing care. All staff at the care home also have opportunities to attend training courses. The staff has achieved a high level of (90 )of NVQ 2 and 3 training. The deputy manager is taking her registered manager’s award. Residents and relative said staff were competent and that they were very satisfied with the staff and felt confident in the care they provide to them EVIDENCE: The staff roster details the deployment of staff. Two care staff are on duty during the day. There is a cook seven days a week and maintenance man is employed. In addition to this Mr and Mrs Butland are actively involved in the home daily. The records for recruitment and appointment for three members of staff contained an application form, two references and a Criminal Records Bureau disclosure and POVA check. Further addition to this area of management responsibility were discussed and appropriateness of person specification and equal opportunities policy would further enhance the protection to residents by the homes recruitment policy and practices. There is a commitment to staff training as evidenced from the training profiles looked at. Staff said that they enjoy the training as it helps them put practice Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 18 into theory and helps them do the job better. Staff are currently completing training in a variety of training such as NVQ, registered manager’s award, moving and handling, first aid and infection control. The residents said that staff appeared competent to do their jobs. Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36,37,38. The home is being managed properly and there is leadership, guidance and direction to ensure residents receive consistent quality care. There is formal quality assurance and control system based on seeking the views of residents to ensure that the home is run in their best interests. Staff receives appropriate supervision to support them to work to the policies and procedures and meet the aims and objectives of the home. The record keeping in general safeguards the best interests of residents. Additions to the record keeping would protect the rights and best interests of residents. Records are kept of events that occur to service users each day but they need to be developed with actions and outcomes. Regulation 26 reports must be produced on the conduct of the home at least once every month by a representative of the company. EVIDENCE: Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 20 The manager has obtained her NVQ at level 4 in care and management and her registered managers award. The residents benefit from her ability to manage the home appropriately and discharge her duties fully for the benefit of the residents. The recent quality assurance and quality control exercise has been completed and was impressive in its content with definite benefits for the residents. Staff receives regular supervision and appraisal and staff meetings take place at regular intervals with minutes records. This report has identified areas that can be improved with resident, staff records and policies and procedures. Residents are encouraged to look at their records. It must be noted that there is a great improvement with the records and the report reflects this. The fire officer inspected the home on the 27th September 2004 and was satisfied with the risk assessment for the premises. Fire training for staff takes place at regular intervals with the trainee and trainer signing the logbook. Fire fighting equipment had been recently serviced. Staff said they have access to reliable advice and guidance from the manager on a day-to-day basis. Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 1 3 3 3 3 3 3 2 3 Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 22 yes 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 7 Regulation 12 and 13 Requirement Environmental risk assessments must be undertaken and recorde when any situation arises that could compromise a residents health , safety and well being. The residents care plans must specify actions and outcomes for residents. Policies and procedures must reflect the role of the multi agencies in adult protection and the Department of health No Secrets. The recruitment and selection arrangements must be further developed to have person specifications and an equal opportunities policy. Training in adult protection for all staff must take place. A copy of any report must be made by a representative of the company at least once a month. Timescale for action 30th Novemeber 2005 30th November 2005 30th November 2005 30th November 2005 Immediate Immediate 2. 3. 7 18 15 schedule 4, 12 and 17 18and 19, sch 2 4. 29 5. 6. 18 37 13(6) 26(4)sch (4) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 23 No. 1. 2. Refer to Standard 12 19 Good Practice Recommendations Management should draw up an action plan to address the socialand leisure activities of the residents. Improvements to the home should continue. Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection John Keay House Tregonissey Road St Austell PL25 4AD National Enquiry Line: 0845 015 0120 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 Polsloe House D04-D52 S62250 Polsloe House V220134 020605 Stage 4.doc Version 1.30 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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