Inspection on 07/11/05 for Polsloe House Ltd

This inspection was carried out on 7th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 02/06/05

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 Ltd Polsloe House 22 Park Road Redruth Cornwall TR15 2JG Lead Inspector Stephen Baber Unannounced Inspection 7th November 2005 09:30 X10015.doc Version 1.40 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 Polsloe House Ltd DS0000062250.V252747.R01.S.doc Version 5.0 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 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 Ltd DS0000062250.V252747.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Polsloe House Ltd Address Polsloe House 22 Park Road Redruth Cornwall TR15 2JG 01209 215337 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) Polsloe House Ltd David Alistaire Butland 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 Ltd DS0000062250.V252747.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd June 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 have owned the home for 1year; previously Mrs Butland was the registered manager. There are 11 single rooms and one double room. Four of the rooms have ensuite facilities. Accommodation is spread out over two floors with toilets and bathrooms near to residents bedrooms.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 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 residents were consulted and they gave me very good feedback on the care and comfort they receive from management and staff. Polsloe House Ltd DS0000062250.V252747.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the unannounced inspection as part of the home’s annual inspection programme on 7th November 2005 commencing at 8:45 am and finishing at 16:15 p.m. The inspector was at the home for seven and half hours The inspection took place over one weekday. The following activities were undertaken whilst at the home 1. Inspection of records, including assessment information and resident recording. 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 2 members of staff and discussion the manager. 5. Individual interviews with each of the 13 residents. 6. Observation of the daily life of the home. 7.No relatives were present on the day of the inspection. The registered manager has made significant improvements in the home and was well prepared for the inspection, which was facilitated by the full cooperation of the residents and staff. The inspection report shows that the management have worked hard to improve the record keeping, policies and procedures and investing significantly in making improvements to the fabric of the home. Residents reported that they felt comfortable and well cared 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. Formal supervision and staff appraisal of staff has been introduced and the quality assurance exercise has been carried out with the residents with positive outcomes for residents. What the service does well: Mr and Mrs Butland have been registered for one year. They have made significant improvements throughout the home and in the care of the residents. There have been improvements in staff training and the staff were very pleased to tell me what they have achieved since the last inspection. The residents said that they were very comfortable and the new residents said the staff were very caring and responsive to their needs. It is very positive to report that Mr and Mrs Butland have planned more improvements in the spring and what was a failing home is now a home where standards are high and staff well trained. Polsloe House Ltd DS0000062250.V252747.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Polsloe House Ltd DS0000062250.V252747.R01.S.doc Version 5.0 Page 7 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 Outcomes Statutory Requirements Identified During the Inspection Polsloe House Ltd DS0000062250.V252747.R01.S.doc Version 5.0 Page 8 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 the following standard(s): 1,2,3,4,5,6. Prospective residents are provided with the information they require in order to make an informed choice about admission to the home. Residents are full assessed prior to admission to the home so they know the home they choose can meet their needs. The home does not provide intermediate care. EVIDENCE: A comprehensive Statement Of purpose and Service User Guide is available. These documents are kept under review in light of the recent changes. I talked with the residents who said they were aware of the documents, which are displayed on the wall in the front entrance. The two new residents files were case tracked. All contained comprehensive information commencing from admission, agreement to care, Moving and handling assessments, medication and risk assessments and individual agreement forms. The manager has devised care planning record which are not specifically daily record come care plans but a daily record with an interventions/action and outcome. This style of document has recently been introduced and the staff Polsloe House Ltd DS0000062250.V252747.R01.S.doc Version 5.0 Page 9 said that it works well because it is the responsibility of the staff to follow up any outcome that they are responsible for. It is also serves as a gooda audit trail for management Polsloe House Ltd DS0000062250.V252747.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 7,8,9,10,11. The health care needs of the residents are identified, planned for and met by the staff and other agencies that work professionally with the home to provide the residents with a good standard of health care. The residents are treated with dignity and respect and policies and procedures for dealing with medication are well managed. EVIDENCE: Two residents files were case tracked. The files contained relevant and detailed information relating to risk assessments, daily recording, care planning and leisure activities preferred by residents. The manager and staff pride themselves on the good working relationships they have forged with all community health care professionals with the aim of providing a good standard of health care to the residents. The homes medication policies are adhered to by all the senior staff who have a responsibility for administering medication. A physical check of the medication cupboard and check of the medication regarded as controlled medication confirmed the security and safety of all prescribed medication to be satisfactory. All members of staff have successfully Polsloe House Ltd DS0000062250.V252747.R01.S.doc Version 5.0 Page 11 completed the Safe Handling Of Medication training. Throughout the inspection I noted the residents be addressed in a courteous manner and with respect by the staff. Polsloe House Ltd DS0000062250.V252747.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 12,13,14,15. The routines of daily living and activities made available are flexible and meet the individual needs of the residents. The residents receive visitors throughout the day thus exercising their right to determine whom they wish to see and where they wish to meet their visitors. The residents are supported by the staff to exercise choice and control over their lives within their capabilities and personal preferences. Management and staff provide the residents with a wholesome appealing diet with attention to detail in the dining room to make for a pleasant dining experience. EVIDENCE: The care planning has changed since the last inspection. The manager has introduced a system of daily recording that details interventions and actions and outcomes that the staff have to take when writing the daily record on the residents. This new recording method, according to the manager and staff makes individual members of staff responsible for following up on individual residents. Another area of improvement is with planned and individual activities. Some residents told me they enjoy going out for a cream tea and a Christmas outing has been arranged to a restaurant for them. I noted the different things people were doing on the day of the inspection Polsloe House Ltd DS0000062250.V252747.R01.S.doc Version 5.0 Page 13 e.g reading, watching television, sitting in the sun lounge, listening to the radio and having conversations with one another. Whilst no visitors were seen I noted the visitors book in the front entrance, which recorded relatives and friends who visit the home. The light and airy dining room has been rearranged so that the residents can see out of the sun lounge. He residents said how much they enjoy their meals and often they said they have too much to eat. There are individual tables in the dining room that seat up to four people. Attention to detail in the dining room has been improved on with good quality crockery, cotton table clothes and vases of fresh flowers on the table. I observed the staff asking the residents what they wanted for tea and noted the wide choice they were offered. Polsloe House Ltd DS0000062250.V252747.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 16,17,18. The complaints procedure is well publicised and used when required. The manager ensures that the residents are protected from abuse by the policies and procedures and staff having knowledge through training of Adult Protection issues, which helps protect residents. EVIDENCE: A comprehensive complaints procedure, which specifies the timescales and types of complaints that can be made, is on display in the front entrance. The residents told me that they knew how to make a complaint and that the manager and staff always took their concerns seriously at all times. There have been no complaints since the last inspection. Explanation was given by the manager on the arrangements in place to protect the residents from financial abuse and how their legal rights are protected.The manager has compiled a new Adult Protection policy and procedure to protect residents from abuse. Minor tweaking of the procedure was pointed out to the manager who agreed to amend the policy and procedure to include the local social services procedure within No Secrets to investigate any complaint regarding the suspected abuse of any resident. CRB and POVA checks are carried out for each member of staff. Training has been arranged for all staff in Adult protection and will be taking place in the coming months. Polsloe House Ltd DS0000062250.V252747.R01.S.doc Version 5.0 Page 15 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 the following standard(s): 22,25,26. The location and layout of the home is suitable for its stated purpose and provides a safe and well maintained environment which meets residents needs Polsloe is and attractive and homely place to live and is clean and fresh smelling. EVIDENCE: There have been major improvements to the home since the new providers have taken over. The following is an example and is not an exhaustive list. • New windows to some areas of the front of the home • The outside of the home has been repainted • New UPVC facia boards and guttering have been installed • Trees have been felled to give the residents abetter view from their windows • New carpets • Redecoration internally • New equipment Polsloe House Ltd DS0000062250.V252747.R01.S.doc Version 5.0 Page 16 • New cupboards etc etc. There is are two chair lifts that go from ground to first floor and there is als aids and adaptations around the home to make life easier for the more dependant residents. Policies and procedures for the control of infection were made available and understood by all staff from induction. It is recommended that no Substances should be left out in the toilets and bathrooms. Polsloe House Ltd DS0000062250.V252747.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30. Residents are protected by the homes robust recruitment policies and procedures that are in place. Management inform and direct staff from induction with a wide range of training opportunities so that the skill mix of staff meets residents needs. Staffing ratios have been increased by day and night to meet the needs of the residents. EVIDENCE: Since taking over as the new providers staff morale seems high resulting in an enthusiastic workforce that work positively with residents to improve their quality of life. Staff duty rota’s showed that there are two care assistants on duty throughout the twenty-four hour period. In addition there are two cooks and one domestic/handyman on duty. Two staff files were case tracked and evidenced that staff recruitment is conducted in line with the policies and procedures of the home. It is recommended that all staff should receive a formal Conditions Of Engagement letter from the manager after completing their probationary period. All staff undergoes Induction training, which ultimately leads onto NVQ training. 80 of the current staff group have achieved NVQ level 2,3,4. Three monthly staff meetings are held and another positive feature of the home is that supervision and appraisal have been introduced so that residents know that staff are appropriately supervised. I spoke with the staff who were pleased to tell me what training they have undertaken since the last visit. Polsloe House Ltd DS0000062250.V252747.R01.S.doc Version 5.0 Page 18 Polsloe House Ltd DS0000062250.V252747.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,35,38. The management team at Polsloe work hard to improve the quality of care to the residents and promote and protect the health, safety and welfare of residents and staff. EVIDENCE: The manager throughout the inspection demonstrated a good understanding of the legislation regarding health and safety. Statutory documentation was in place that evidenced the various service documents and reports. The fire records were found to be up to date and in sufficient detail with staff receiving fire instruction at the recommended intervals. The manager has carried out an internal audit of quality assurance, which includes opinions from residents, staff and relatives. It is recommended that the survey should be extended to include the external opinions of the community nursing, general practitioners and any other interested stakeholders. Documentary evidence shows that staff Polsloe House Ltd DS0000062250.V252747.R01.S.doc Version 5.0 Page 20 receive training in Health and Safety from induction and some of the areas covered are Basic Food Hygiene, First Aid, Moving and Handling and Cross Infection. Polsloe House Ltd DS0000062250.V252747.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 X X X 3 X X 3 2 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 X X 3 Polsloe House Ltd DS0000062250.V252747.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP18 OP26 OP29 Good Practice Recommendations Minor amendments to the adult protection policies and procedure as set out in the body of the report should be made. Containers of hazardous substances should be kept in a locked cupboard. Conditions of Engagement letter should be given on completion of a satisfactory probationary period. Polsloe House Ltd DS0000062250.V252747.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall 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 Ltd DS0000062250.V252747.R01.S.doc Version 5.0 Page 24 - 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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