Inspection on 04/07/06 for The Polegate Nursing Home

This inspection was carried out on 4th July 2006.

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 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

The Polegate Nursing Home 11/03/08

The Polegate Nursing Home 09/02/06

The Polegate Nursing Home 28/09/05

The Polegate Nursing Home 20/12/04

The Polegate Nursing Home 11/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE The Polegate Nursing Home The Polegate Nursing Home Blackpath Road Polegate Eastbourne East Sussex BN26 5AP Lead Inspector Debbie Calveley Key Unannounced Inspection 4th July 2006 08:30 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 The Polegate Nursing Home DS0000014027.V301959.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 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. The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Polegate Nursing Home Address The Polegate Nursing Home Blackpath Road Polegate Eastbourne East Sussex BN26 5AP 01323-485888 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) ANS Homes Limited Mrs Jacqueline Taylor Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44) of places The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That the maximum number of service users to be accommodated is forty-four (44). To care for chronically ill service users under the age of sixty-five (65) years under the continuing care criteria. To care for chronically ill service users over the age of sixty-five (65) years under the continuing care criteria. 9th February 2006 Date of last inspection Brief Description of the Service: The Polegate Nursing Home was purpose built in May 1996 and accommodates up to forty-four service users with continuing care needs under the Health Authority’s eligibility criteria. The home is registered to provide care for service users falling in to the category of older people and those with a physical disability. The home was purpose built to provide single bedrooms with ensuite facilities to heavily dependent service users with a need for continuity of care from hospital. The resident’s accommodation is on two floors; each of these floors is provided with a large lounge. The lower floor has a dining room, which caters for all residents, and most group activities are held in this room. All areas of the home are assessable to service users, the corridors are wide enough to accommodate self-propelled / electric wheelchairs and the lifts are spacious. The rooms are spacious to allow room for hoists and other specialist equipment whilst maintaining a homely and comfortable environment. The décor of the home is pleasant, simple and well maintained and the furniture is of a good quality. There is a garden area with a patio that is accessible to service users in wheelchairs. There are suitable toilet, bathing and washing facilities provided to meet the needs of the service users, all with equipment designed for less abled persons. There are car-parking facilities to the rear of the property for approximately 25 cars. The home is in the centre of Polegate village, close to the shops, railway station and major bus routes. The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 5 Copies of inspection reports and the homes Statement of Purpose are made available on request. Fees charged as from 1 April 2006 range from £575 to £749, which does not include toiletries. Additional charges are made for hairdressing, chiropody, newspapers and outside activities such as visits to the theatre. Intermediate care is not provided. The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Polegate Care Home will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with resident’s representatives and visiting health and social care professionals. This unannounced inspection was carried out over 8 hours on the 04 July 2006. A second visit to deliver further surveys to relatives and residents was made on the 06 July 2006. There were thirty-six residents in residence on the day, of which eight were case tracked and spoken with. During the tour of the premises ten other residents both male and female were also spoken with. The purpose of the inspection was to check that the requirements of previous inspections had been met and inspect all other key standards. A tour of the premises was undertaken and a range of documentation was viewed including the service users guide, statement of purpose, care plans, medication records and recruitment files. Six members of care staff, two trained nurses, physiotherapist, and the cook were spoken with in addition to discussion with the Registered Manager. The pre-inspection questionnaire was received back from the registered manager on the 21 June 2006 completed in full. Comment cards received from twelve residents and two relatives were generally positive and indicated that both groups were satisfied with the services provided. Two comment cards were received from social and healthcare professionals, and eight staff surveys were received from a selection of staff. The information contained in the returned surveys has been incorporated into this report. What the service does well: The Statement of Purpose and Service Users Guide give prospective residents the information required to enable them to make an informed choice about where they live. All parts of the home were clean, comfortable and well maintained. The quality and choice of meals remain good and all residents spoken with confirmed this. “ The food is good” “we get a choice of food everyday” “ the food is always freshly prepared”. The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 7 Systems are in place to regularly consult with residents via service users meetings and surveys. There is an open-house policy, which welcomes visitors at all reasonable times. Satisfactory arrangements are in place to safeguard resident’s finances. Staff provision is well maintained with good recruitment practice being followed and appropriate numbers of staff suitably qualified working in the home. The staff group on the whole is stable. Both residents and their relatives spoke highly of all the staff saying ‘staff are always nice and kind’ ‘staff are helpful, approachable and are available to talk to’. The training for staff is good, and covers a wide variety of resident related conditions, which give the staff an understanding of the residents needs. What has improved since the last inspection? What they could do better: The care plans whilst improved in relation to identifying and implementing a plan of action to meet the physical needs, still need to be developed in respect of their social and personal needs. Such as communication, depression and personal choice. Fluid charts for the physically frail residents need to be completed on a regular basis, to give an accurate reflection of their hydration status. The staff need to ensure that there are jugs of fluid available in the lounge areas at all times, but more so during the heat wave. The activity programme needs to be reviewed to reflect the differing needs of the residents living in the home. The residents would benefit from a more The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 8 stimulating environment in the lounge areas to encourage residents to interact and prevent isolation. A recent Adult Protection investigation evidenced that the senior staff need to ensure they are totally familiar with the alert mechanism of the adult protection procedures. All residents need to have access to a call bell or a system for staff to follow in supervising the lounge areas to ensure that residents are safe and comfortable. Any incident that affects the safety and well being of the residents needs to be recorded, investigated and action taken and evidenced to prevent a reoccurrence of the incident. Robust Health and safety systems need to be adopted and recorded to ensure staff and resident safety. 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 Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 9 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 The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 10 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 and 5. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Prospective residents and their representatives are provided with information about the home in order to make an informed choice about whether to live at the home. The pre-admission assessment procedures ensure residents admitted can have their care needs met within the home by experienced staff. EVIDENCE: A Statement of Purpose and Service Users Guide, which conforms to the Care Homes Regulations and National Minimum standards, is in place. It is available to all residents and their relatives and is written in a clear and user-friendly format. It has been updated and individualised to the home. Information regarding the short-term G.P beds is at present inserted in to the Service Users Guide of the residents admitted via this criteria. It is not confirmed as yet as to whether the home will continue this service. It was confirmed whilst talking to residents that the contract arrangements were clear and understood. The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 11 A review of the care documentation confirmed that pre-admission assessments are completed, and are currently completed by the manager or a senior nurse. Six of the seven assessments were found to be completed and were used to ensure new admissions to the home were suitable and that the home have the staff and environment to meet the care needs of the new resident. The information contained in these assessments is then used to provide the basis of the care documentation in the home. The prospective residents’ are seen either in their home or hospital before admission and the manager confirmed that wherever possible the family or representative is involved. At present twelve beds are being used for G.P admissions and in some instances when it is an emergency admission, the pre-admission assessment is not completed, but the home ensure that as much information as possible is gathered from the admitting G.P and that a full assessment of needs is completed on admission to the home. It was an acknowledged problem that the time constraints on the short-term admissions are not being adhered as stated in the contracts and meetings are on going to address these areas between the Registered Providers and the Primary Care Trust. The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 12 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 and 10. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Generally care plans provide a good framework for the delivery of care, however these need to provide clear guidance to care staff on all the care and social needs of residents. The home was found to be meeting resident’s health and general needs. Procedures and practice in the home allow for the safe administration of medicines and on the whole the privacy of residents is promoted. EVIDENCE: The care documentation pertaining to eight residents was reviewed as part of the inspection process. These were found to include plans of care, nutritional assessments, and risk assessments. On the whole the care documentation was improved and demonstrated that the health care needs were reviewed and evaluated, however it was noted that the plans of care did not always cover all the social and personal care needs of residents. For example one resident who has communication problems did not have any guidance in the documentation The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 13 to facilitate this vital need, another resident was identified as suffering from depression, but again no clear action plan devised for staff to follow to give support to the resident. Personal histories are being completed on the residents, but still need to be developed further. The documents used to monitor fluid intake were again found not to be completed between the hours of 5:30 pm and 08:00 am, thus not giving a correct reflection of the hydration status of the resident. This was brought to the senior staffs’ attention during the inspection as it indicates 14 hours without an offer of fluids. It was also noted that residents in the lounge at 11:00 am, did not have access to fluids, even though it was an extremely warm day and the Inspector when chatting to the residents was asked by the residents for a drink. The staff were asked immediately to ensure that jugs of water/squash be available, and this was addressed at the time. Nutrition records are being updated monthly and evidence that residents are being weighed regularly, however weight loss though identified was not followed through with a care/action plan to guide staff in addressing this problem. The clinical rooms were clean and tidy, the equipment well maintained. There are policies and procedures in place for the storing, administrating, disposal and receipt of medication. The temperature of the fridge and room are recorded daily and of an acceptable temperature to maintain dressings and medications. The medication administration charts were viewed and were seen to be correctly completed. A self-administering policy is in place, and residents are encouraged and supported to administer their medication with a risk assessment framework. One resident currently self-administers her medication. From direct observation the residents were seen to be treated with respect. Feedback from three residents suggested that the staffing ratio of male and female staff need to be reviewed and needs to reflect the residents’ wishes. The night shift on one unit has had two male staff and the female residents felt that it compromised their dignity. Another resident said that she was happy in the home, but felt that being cared for by two males when getting up and dressed in the morning was something she would never feel comfortable with. It is asked that all residents are asked their preferences regarding gender of staff on admission to prevent embarrassment and residents feeling uncomfortable. The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 14 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 and 15. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Residents would benefit from a more robust and stimulating activity programme. The lifestyle experienced by residents does not always match their expectations, choice or preferences. Meals remain good in respect of both quality and variety that meets residents’ tastes and choice. EVIDENCE: Activities take place on a daily basis usually in the afternoon between 2 pm and 4 pm. A monthly programme is given to all residents individually as well as being displayed on notice boards around the home. Activities offered were music from various people up to three times a week, bingo, clothes and toiletries shop and in June, some world cup sessions took place making banners and a collage. Residents would benefit from a more robust activity programme that is based on the residents’ individual preferences and capabilities. The activity programme needs to be reviewed to provide more motivation and stimulation. The Inspector was concerned regarding the amount of residents spending long periods of time in their rooms, with little interaction seen. The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 15 Residents spoken with and whom were bright and alert decline to attend most of the activities. Reasons given were varied, but many said they did not find the sessions interesting and found it uncomfortable for them personally. Residents in the short stay unit said they did not see any one on a one to one basis and did feel isolated. Two residents admitted to feeling bored and lonely, and a further two said that the activities provided were not for them. Feedback from staff surveys regarding areas that could be improved included the following comments: “More activities for the residents and not just for one hour. Some people would like to things that keep them out of their rooms for longer”. “That residents have more activities and motivation, especially the private more abled residents”. “More motivation and activities to make the home their own”. At present there are three very differing categories of residents in the home, twelve are very heavily dependent residents placed by the Primary Care Trust, twelve are private residents and the majority of them are alert, though physically frail with medical complications and twelve are short term placements with a view to going home. It is a difficult problem to meet all the varying social needs of all the residents living in the home in the one-hour session, however it was noticeable that residents were feeling isolated and bored and this needs to be addressed. The care plans also need to reflect how residents are encouraged and supported to participate in activities. There are no restrictions on visiting times as long as consideration is shown to all the residents. One resident survey said “ I miss not having access to telephone and so find contact with my friends difficult”. The lounges are available to residents and their visitors for private meetings if their own rooms are not appropriate. Three relatives spoken with confirmed that that they can visit at any time and are always made to feel welcome. One relative arrives at 11 am and stays all day with his wife and leaves at 5pm. He eats meals with her and is content just to sit with her. Another relative said “ This place is wonderful, I can not fault anything” The home has an advocacy policy in place and the information regarding this is available to all residents. Menus are distributed to all residents and are also on display in the dining rooms. They demonstrated choice and variety and were indicated a well balanced diet. The menus rotate on a four weekly basis and change according to the seasons. The lower floor dining room can accommodate a large percentage of the residents; however on the day of the inspection the residents that can choose to eat in the dining room all chose to eat in their own bedroom. The reasons for this have been discussed with the Registered Manager and responsible individual and will be reviewed. The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 16 The kitchen is efficiently run, clean and well organised. All cleaning and temperature checks are recorded and available for viewing. The chef is knowledgeable of the likes and preferences of the residents. One resident who admits to being ‘fussy’ said, “He visits to discuss her wishes and has listened to her regarding her personal preferences. Comments from surveys received included “ the food is excellent”, “fantastic food”. During the tour and chatting to the residents there was some negative comments regarding the suppers provided and the weekend quality of cooking. The manager confirmed that she is aware and is addressing the problem. The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 17 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 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a satisfactory complaints system with evidence that residents felt confident their views would be listened to. Staff have been trained in the protection of adults, improvements need to be made to ensure they remain familiar with procedures so that residents are not at risk of harm or abuse. EVIDENCE: There are appropriate complaint policies and procedures in place and it was confirmed that these are followed when investigating any concerns raised at the home. The complaint book was viewed and this demonstrated that all complaints are recorded, along with the outcome and action taken by the home to resolve the complaint. One complaint was seen recorded since the last inspection and there was evidence of the investigation and outcome. The staff interviewed were aware of the complaint procedure and of how to start the process if the manager is not available. Three of the residents referred to the service users guide when asked if they knew how to make a complaint, whilst one resident said he had seen a brochure. Two residents in the short stay unit said they were not aware of a complaint procedure or a service users guide. One resident said she would talk to the nurse in charge if she had a problem. There have been no complaints received by the CSCI. The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 18 The Adult Protection policy in the home was found to be up to date and staff interviewed were knowledgeable about the systems in place to protect vulnerable residents. There is on-going training for all staff in Adult Protection. A recent Adult Protection investigation evidenced that the senior staff need to ensure they are totally familiar with the alert mechanism of the adult protection procedure if they are the ones that are raising the concerns. There was a significant delay in completing paperwork and initiating the investigation, which could have complicated the course of the investigation. The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 19 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): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home provides a comfortable, clean and safe environment for those living there and visiting. Residents are enabled and encouraged to personalise their room, and rooms are homely and reflect the resident’s personalities and interests. EVIDENCE: A tour of the premises was carried out and all parts of the home are well maintained and the décor is of a good standard. The home was purpose built and all bedrooms have an ensuite bathroom. The residents are encouraged and enabled to personalise their rooms with furniture and pictures, and this was evident during the tour. All personal items are listed in the individual care plans. The accommodation for residents is on two floors with level access to the garden on both floors. Each of these floors is provided with a large lounge. The The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 20 lower floor has a dining room with an adjoining small kitchen, which caters for all residents at lunchtime. Most group activities are held in this room. The lounge area on the first floor was found to be crowded with too many lounge chairs around the perimeter, so the residents are found in rows in their chairs with the television as the focus point. It was not found to be a stimulating environment for the residents. The more mobile and able residents admitted not to using the lounge and preferred to stay in their room. This is an area the staff need to work on and develop so that all the residents benefit from the lounge areas and are not isolated in their rooms. The communal rooms are non-smoking and residents wishing to smoke do so in their own rooms, following an individual risk assessment. There are suitable toilet, bathing and washing facilities provided to meet the needs of the resident’s, all with equipment designed for disabled and frail people. The home is well equipped with equipment to meet the needs of residents’, and the senior staff are aware of where to procure any specialised equipment. This, in conjunction with the input from the Physiotherapist ensures that the needs of the residents are fully met. This multi-disciplinary approach is recorded in the shared care records. Senior staff confirmed that residents that do not have the capacity to ring their call bell are checked regularly, however this did not happen in the lounge areas. Residents were asking the Inspector for drinks, to switch on the fan and asking for assistance. The staff need to be very vigilant of residents needs especially during the heat wave. This occurred mainly during the morning. The home has a legionella policy in place and all hot water outlets are thermostatically controlled and are tested on a regular basis. Random outlets were tested and were of the required temperature. Polices and procedures for infection control are in place and are updated regularly. The home was clean and free from offensive odours on the day of the inspection. Good practice by staff was observed during the day and there were gloves and aprons freely available in the home. Sluices and laundry areas were found clean and safe. The home provides a good laundry service. The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 21 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, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staffing arrangements are good and suitable and ensure the needs of the residents living in the home are met. Residents are protected by the home’s recruitment policy and practices. EVIDENCE: The staffing rota was viewed and the staffing levels were seen to be sufficient to meet the needs of the residents at this time. However the delegation of staff regarding supervising the lounge areas needs to be reviewed. It was confirmed by the manager that there is flexibility of the staffing levels and they are adjusted according to the changing needs of the residents. Staff spoken to said that they felt the levels of staff on duty were sufficient to give the care required, they also said that the trained staff do help out. Two residents also confirmed that they had no complaints regarding the amount of staff, one resident said the “staff are always helpful, they look after me very well”. Another said, “ The staff are really nice, but don’t get time to linger and chat”. The staff group on the whole is stable both residents and their relatives spoke highly of all the staff saying ‘staff are always nice and kind’ ‘staff are helpful, approachable and are available to talk to’. Two surveys received stated that there is sometimes miscommunication due to a language barrier. The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 22 The recruitment records for 5 staff members were reviewed in depth and were found to be full and contain the required information and demonstrated the appropriate induction training had been completed in respect of the job they were to undertake in the home. Staff interviewed confirmed a high satisfaction with the training provided and stated that that some topics were useful and interesting. Staff and records seen, confirmed that they had undertaken compulsory training such as manual handling, adult protection, first aid, and food hygiene and fire safety. NVQ training is available and staff are encouraged to complete this. At present 22 care staff have completed or are on the NVQ programme. The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 23 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, 33, 34, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The overall management of this home is good with effective systems in place to protect service users. EVIDENCE: The Manager is a first level registered nurse and has been a manager for six years within the organisation. She has a diploma in management studies. The manager has suitable qualifications and experience to run the home competently. She takes responsibility for the day-to-day running of the home and is supernummery to the care and nursing staff; she is also on call for any emergencies. The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 24 The formal quality assurance and quality monitoring systems in place enable the management to objectively evaluate the service and ensure it is run in service users best interests. There are systems in place to safeguard resident’s financial interests; with policies and procedures in place for staff to follow in respect of gifts and rewards from residents and their families. The manager confirmed and the staff training records show that all staff are kept updated on the Health and Safety policies, the manual is available to all and clearly defined. Staff were able to discuss the training they received and said that they were kept up to date with changes to policies in connection with fire safety and health and safety. Feedback from staff surveys stated “ We work together as a team”, “The support from all staff ensure we work well together”, “I feel supported to do my job”. The staff are issued with certificates yearly for Manual Handling, twice yearly for Fire Safety and Food and Hygiene. The home has a comprehensive set of policies and procedures, which govern the running of the home. All relevant legislation and procedures are in place in respect of Health and safety. Evidence was seen of regular supervision sessions and all staff spoken with and those that completed staff surveys confirmed that they receive regular supervision. Documents relating to safe working practices and Health and Safety were available and found to be satisfactory as were accident records. However all incidents involving residents slipping or falling need to be documented, investigated and an action plan put in place to ensure that it does not happen again. Good practice was observed throughout the inspection regarding the moving and handling of residents. As previously mentioned all residents need to have access to a call bell or a system in place that ensures that the residents are checked regularly. The Polegate Nursing Home DS0000014027.V301959.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 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 2 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 3 3 2 The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation Requirement Timescale for action 04/08/06 15(2)(b)(c That a comprehensive plan of )12(1) care is generated from a comprehensive assessment is drawn up for/with each service user, and it is reviewed at least once a month. This to include social and personal care needs. That consultation with the service user/representative is evidenced when the care plan is devised. 2. OP8 13(1)(b) 17(1)(a) That all documentation in 04/07/06 respect of residents health needs are kept up to date, reviewed regularly and assessable to all staff as per schedule 3.( Previous timescale of 01/04/06 not met.) That the residents’ health needs 04/07/06 are conducted in a manner which respects the privacy and dignity of residents. That all residents are given 01/10/06 opportunities for stimulation through leisure and recreational activities in and outside of the DS0000014027.V301959.R01.S.doc Version 5.2 Page 27 3. OP10 12 (3)(4) 4. OP12 12 (2) 16 (2) The Polegate Nursing Home home which suit their needs, preferences and capacities. That service users isolated in their bedrooms have a plan of care to ensure that they receive interaction and stimulation. All allegations and incidents of abuse are followed up promptly and action taken is recorded. That staff are aware of the procedures to initiate an Adult Protection investigation. That all service users have access to a call bell, or a method of recording that the staff are regularly checking those service users who cannot use this facility. That a record of any incident which is detrimental to the health or welfare of a service user is completed and a planed action put in to place to prevent a reoccurrence. 5. OP18 12(1) 17(1) 04/08/06 6 OP22 OP38 16 (1) 04/07/06 7 OP38 17 (1) (4) 04/07/06 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 OP15 OP38 Good Practice Recommendations That a more formal way of recording the amount of food eaten is recorded. That a more detailed action plan detailing prevention of incidents is document on the accident forms. The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 The Polegate Nursing Home DS0000014027.V301959.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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