Care Home: Polebank Hall

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What the care home does well The new manager has been in post since August 2007. During this time she has provided stable management and good support for the staff team. This aspect of her role was reflected by the positive comments made from residents, relatives and staff. Residents and relatives indicated that they felt they could approach the manager with any concerns and confirmed that she operated an `open door` policy. Staff confirmed that they were supported well by the manager both on a formal and informal basis. Some areas of the home have been refurbished in the last 12 months, and the layout of the home provides useful space for residents to meet with their families and friends. There is a pleasant outdoor space, which provides a relaxed and safe environment for residents to enjoy in the warm weather. The manager provided details of further plans to improve the internal features of the home and said that she was working towards an ongoing programme of redecoration and refurbishment. The home provides existing and prospective residents with a care information pack which includes a service user guide, and useful information about the facilities and services provided by the home. The manager or a senior member of staff from the home carries out assessments, so that staff are confident that the skill mix of the staff team and the resources available are sufficient to meet the needs of individual residents. The home had taken positive steps to address requirements and recommendations made at the last key inspection, and shown a commitment to developing the service so that residents have better outcomes and quality of life . All the requirements from the previous inspection report have been addressed, and there were no requirements made at this inspection. The staff recruitment programme is robust and ensures that the well being of residents is protected. During the visit, there was a calm and relaxing atmosphere, and residents were seen moving around the home in a purposeful way, and were encouraged by staff to use the facilities, e.g. the small seating areas. Overall, the comments from residents and relatives were very positive, and most residents who were spoke to were happy about the way in which staff provided care and support. Residents` comments included: "The manager and staff are excellent. They always respond to call no matter what time of day it is. There is always a welcoming atmosphere and it is a calm and peaceful place". "Staff keep us informed and ring us if there is a problem". "It`s very good here. The staff are always pleasant and helpful". "They make sure my husband`s care and spiritual needs are met". " I feel very confident about the care here". What has improved since the last inspection? The recommendations from the previous inspection had been addressed. The main area of improvement has been care plans, and further improvements are ongoing. This will ensure that staff have the correct information to help them in meeting the care and support needs of residents in the home. The appointment of the manager has ensured a stable management structure and support for the staff team. All new staff receive induction and ongoing supervision which leads to further training and development opportunities. This ensures that the staff have the right skill mix to meet the needs of residents. Some improvements have been made to the decorations and furnishings in the home and the manager stated her plans for a rolling programme of improvements. One particular feature is a pleasant patio at the side of the building which provides a relaxing and pleasant area for residents to enjoy in the good weather. What the care home could do better: Information in the AQAA shows that the manager has a good understanding about what needs to be done to continually improve the service. The organisation should continue to develop services and fulfil the plans for improvement as identified in the self assessment information, contained in the AQAA. CARE HOMES FOR OLDER PEOPLE Polebank Hall Stockport Road Gee Cross Hyde Tameside SK14 5EZ Lead Inspector Ann Connolly Unannounced Inspection 10:45a 3rd July 2008 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 Polebank Hall DS0000005576.V375591.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. Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Polebank Hall Address Stockport Road Gee Cross Hyde Tameside SK14 5EZ 0161 368 2171 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) Polebank Residential Care Home Limited Manager post vacant Care Home 29 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (29), Old age, not falling within any other category (29), Physical disability over 65 years of age (16), Sensory Impairment over 65 years of age (3) Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users up to 24 (DE) (E); up to 3 (SI) (E); up to 29 (MD) (E); up to 29 (OP) and up to 16 (PD) (E) 18th July 2007 Date of last inspection Brief Description of the Service: Polebank Hall is a large detached property situated in the centre of a public park. Formerly a mill owner’s house, it now has listed building status. The property has been adapted and extended over the years to provide accommodation on three floors in 25 rooms, 11 of which have en-suite facilities, and two shared rooms both with en-suite facilities. The lounges and dining room are on the ground floor. There is also a large conservatory to the side of the building. Polebank Hall is located within a public park. The home does not have a secure garden space dedicated for the residents’ use. It would appear this does not have a detrimental effect on the residents who take great delight in watching the comings and goings of the general public who also use the area. Fees for accommodation and care at the home range from £315 to £440. Additional charges are also made for hairdressing and chiropody services, newspapers, personal toiletries and trips. Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes This was a key inspection that included a site visit to the home. The manager was not told beforehand that we were coming to inspect, this is called an unannounced inspection. This inspection looked at all the key standards and included a review of all available information received by the Commission for Social Care (CSCI) about the service provided at the home since the last inspection. During the site visit a selection of records, care plans, policies and procedures were examined. Discussions took place with the manager, staff working in the home, and some relatives who were visiting. A tour of the home was undertaken and residents were asked for their comments and views about the environment. Several residents living in the home were spoken to in private during the visit, and discussions took place with them to find out what they thought about the home and what they felt about how the staff supported them. Before the inspection, we also asked the manager of the service to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well, and what they needed to do better. This is one of the ways that we get information from the manager of the service, about how they are meeting outcomes for people using their service. Information that was provided in the AQAA for this service, was detailed and comprehensive, and provided evidence of a service that was committed to focusing on positive outcomes for the people who use the service. Since the last inspection visit, which took place on 18th July 2007 , the Commission for Social Care Inspection received one concern about this service. The home followed safeguarding procedures in this instance and the appropriate professionals were involved. Following the investigation of social services this allegation was unfounded. There was evidence during this visit that the manager was managing complaints well, and that procedures were followed appropriately. Over the last twelve months the home’s manager has received two complaints, and information in the AQAA states that these were investigated within 28 days. In both these cases appropriate action was taken to address the concerns to the complainant’s satisfaction. Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 Page 6 What the service does well: The new manager has been in post since August 2007. During this time she has provided stable management and good support for the staff team. This aspect of her role was reflected by the positive comments made from residents, relatives and staff. Residents and relatives indicated that they felt they could approach the manager with any concerns and confirmed that she operated an ‘open door’ policy. Staff confirmed that they were supported well by the manager both on a formal and informal basis. Some areas of the home have been refurbished in the last 12 months, and the layout of the home provides useful space for residents to meet with their families and friends. There is a pleasant outdoor space, which provides a relaxed and safe environment for residents to enjoy in the warm weather. The manager provided details of further plans to improve the internal features of the home and said that she was working towards an ongoing programme of redecoration and refurbishment. The home provides existing and prospective residents with a care information pack which includes a service user guide, and useful information about the facilities and services provided by the home. The manager or a senior member of staff from the home carries out assessments, so that staff are confident that the skill mix of the staff team and the resources available are sufficient to meet the needs of individual residents. The home had taken positive steps to address requirements and recommendations made at the last key inspection, and shown a commitment to developing the service so that residents have better outcomes and quality of life . All the requirements from the previous inspection report have been addressed, and there were no requirements made at this inspection. The staff recruitment programme is robust and ensures that the well being of residents is protected. During the visit, there was a calm and relaxing atmosphere, and residents were seen moving around the home in a purposeful way, and were encouraged by staff to use the facilities, e.g. the small seating areas. Overall, the comments from residents and relatives were very positive, and most residents who were spoke to were happy about the way in which staff provided care and support. Residents’ comments included: “The manager and staff are excellent. They always respond to call no matter what time of day it is. There is always a welcoming atmosphere and it is a calm and peaceful place”. “Staff keep us informed and ring us if there is a problem”. Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 Page 7 “It’s very good here. The staff are always pleasant and helpful”. “They make sure my husband’s care and spiritual needs are met”. “ I feel very confident about the care here”. 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. The summary of this inspection report can be made available in other formats on request. Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 (Standard 6 was not assessed as Polebank Hall does not provide intermediate care). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are given sufficient information about the home to help them in making a decision about their care arrangement. Residents’ needs are assessed prior to admission to the home so they are confident their needs will be met, and the home is sure it can meet their personal needs. EVIDENCE: The home has a Statement of Purpose and a Service User Guide, which provides existing and prospective residents with information about the service. This means that people can make an informed decision about their care and support arrangements. The guides are well presented, and are available from the manager. Information in the AQAA states that all prospective residents and Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 Page 10 their families are offered a photocopy of the latest inspection report in order to give them additional information on how the home is performing. Three care plans were examined and they contained assessments carried out by the care manager from the placing authority. In addition, an assessment of care needs was carried out by the manager, or representative from the home. The information obtained was used to develop a care plan for each resident. During this site visit, the manager had just returned from visiting a prospective resident in his own home and had started to complete the pre admission information. She said that this visit provided an opportunity to allay any anxieties the prospective resident might have, offer introductory visits to the home, and to provide information about the services offered at Polebank hall. Prospective residents are given a copy of the service user’s guide which provides details about the care home and important information about the conditions of residency, the complaints procedure, the facilities and information about the staff team. All this information helps the prospective resident to decide if this is the right place for them to move into. The manager has developed a letter which she intends to give to all prospective residents that she has assessed. This provides them with written information stating and confirming that the home can meet their assessed support and care needs. Residents receiving this information are given additional confidence that their needs have been assessed and considered before a place is offered to them. Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans provided staff with the information they need to meet and monitor the resident’s needs. Medication practices ensure that residents receive their medication safely. EVIDENCE: Three care plan files were looked at, including the files of a person recently admitted into the home. Since the last inspection the manager has carried out significant work on developing the care plans, and information in them showed evidence of a person centred approach. However, some of the documentation needed further development so that each newly identified care and support need is clearly identified with the relevant information for staff on how to support this need. The manager was aware of this shortfall and during this visit we saw some examples of new care plan documentation which provided evidence that the Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 Page 12 manager had a good understanding of what needed to be included in care plans to ensure that staff had the right information to help them to support residents in an appropriate and safe way. The three care plans that were looked at included a brief history which provides information about the resident’s past, interests and daily living needs. There was a strong focus on consulting with residents on how they wanted to be supported and how they wanted to lead their day to day life. There was evidence of care plan reviews and records to show who was involved in the review process. The review format was useful as it detailed the areas that had been looked at and recorded what changes needed to be made as a result of the review. One relative said , “ The staff are very good, they keep us informed and ring me if there’s a problem. The staff are really good at trying to meet needs”. It was evident from discussions and observations of staff during the course of their duties that they had a good knowledge and understanding of individual care needs. Relatives who were spoken to said that the care staff were always knowledgeable about individual care needs and always knew the answer to any queries about their health care needs. She went on to say, “They deal with medical problems and he is helped to go to the hospital or see a doctor if this is needed”. The home maintains records of any medical intervention and involvement of health care professionals to ensure that resident’s health care needs are met and that they are supported appropriately. Medication was administered using a monitored dosage system. Medication administration records (MAR),were appropriately maintained. Staff were able to demonstrate the correct procedures for administering medication. There was evidence of good practice and specimen signatures of all staff responsible for the administering of medication were included in the records. This provides a tool for tracking when audits are carried out. There were no gaps on the medication administration records (MAR) which shows that residents are receiving their medication as prescribed. Controlled drugs were examined and all records were accurate and up to date. Throughout the visit, staff were seen engaging in meaningful conversations with residents and were respectful at all times. Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to engage in the daily life in the home, and the home supports and encourages residents to maintain links with their family and friends. This allows residents to exercise as much choice and control over their lives as they can. Meals served to residents were of a high quality, providing a well presented and nutritionally balanced meal EVIDENCE: The home has an open visiting policy, and information about visiting arrangements was included in the statement of purpose and service user guide. Residents who were spoken to confirmed that they could receive visitors at any time, and a number of visitors were seen coming and going during the course of this inspection visit. It was noted that visitors were made welcome on arrival, and from discussions with some of them, it was evident that visits to Polebank Hall were seen as a positive and pleasant experience. Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 Page 14 The person centred planning approach provides opportunity for residents to express their social interests and their lifestyle preferences. There was evidence that residents were consulted on admission about their interests. Information in the AQAA provided by the manager acknowledges that the activity programme needs further development so that residents are offered activities on a regular and consistent basis. Some residents and their relatives said they would like more activities to be available. The lunchtime meal was a relaxed and social occasion. New dining room furniture had been purchased, and the setting provided opportunity for residents to get together and join in conversations. There was a choice of meal which was pastie or sandwiches and a jam sponge and custard for dessert. The meal was well presented and looked appetising. The main meal is served in the evening and provided well-balanced options. All residents who were spoken to said the meals were always well presented and ‘very tasty’. Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ rights are protected by robust polices and procedures and there is an open transparent approach to managing complaints. EVIDENCE: There is a complaints procedure in place, which is displayed prominently around the home. This gives details and timescales by which a complainant can expect a response and also provides the contact details of the Commission for Social Care Inspection. There is a complaints record, where all complaints which are brought to the attention of the manager are logged. It details the nature of the complaint, the action taken and the outcome for the complainant. Since the last inspection the home has not received any complaints. The Commission have not received any complaints about this service. One concern was received which was appropriately dealt with by the home. Staff who were spoken to had a good understanding of issues around abuse and what to do in the event of an allegation of abuse. Some staff had a more in depth knowledge that others, and were fully aware of the procedures. The manager stated that all staff had received training on adult protection and Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 Page 16 safeguarding, to ensure that all staff have a detailed knowledge base. The manager said that safeguarding practices are re-inforced in supervision sessions so that staff are confident in procedures and know what happens once an allegation has been reported to the manager. Residents who were spoken to during this visit indicated that they felt confident in approaching the staff and the manager with any concerns. Relatives who were spoken to said they felt they could talk to the manager or a member of staff at any time with a concern because they were , “So approachable”. Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Polebank Hall provides the residents with a warm, welcoming home. There are high standards of housekeeping and maintenance. EVIDENCE: It is understood that Polebank Hall is a listed building located in the centre of a public park. Internally it retains all the splendour associated with an English country house. The registered provider leases the building from the local authority. The responsibility for the upkeep of the external building is an issue that is under discussion with the registered provider and the local authority. This was an unannounced visit to the home. As part of the visit, a tour of the building took place. Communal areas and bedrooms were found to be tidy and were cleaned to a high standard. Discussion with the manager provided Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 Page 18 evidence that all staff have been made aware of infection control, and there was evidence during the visit that protective clothing was provided, and used by staff. All toilet areas were fitted with soap dispensers and paper towels. The manager provided documentation confirming that all health and safety checks had been carried out in the environment and on equipment as required. There was evidence of an ongoing rolling programme of decoration and refurbishment. Overall, a pleasant environment was provided for residents and visitors. The external garden and patio areas had been thoughtfully designed to provide an extremely pleasant and safe external area for residents to enjoy all year round, making good use of the external space. Good use was made of internal space, with quiet lounge areas so that residents could meet with their families and friends in privacy and comfort. There was evidence that bedrooms had been personalised with personal effects and furnishings. All residents spoken to and visitors at the time of the visit were highly complimentary of the standards in the home. Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 Page 19 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. 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 using available evidence including a visit to this service. Residents are supported by a well-trained staff team, and are protected by robust recruitment procedures. EVIDENCE: At the time of this visit, there appeared to be sufficient numbers of staff on duty to meet the needs of residents in the home. The atmosphere in the home was relaxed, and staff were seen engaging in meaningful conversation and interactions with residents. All comments made by residents about staff were extremely positive. Comments included: “The staff are so very good. If you want something you can always go to them and they will get it for you”. “Staff are very good, they will do anything for you”. “I can’t say a wrong word about the staff, they are always pleasant and cheerful”. Three staff files were examined, these were well organised with a clear index system for reference purposes. One of the files looked at was of a recently recruited member of staff. All files examined contained appropriate paperwork Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 Page 20 and Criminal Record Bureau checks and two written references. An employment history was also included on the files. Staff files included details of training. Staff who were spoken to confirmed that there were plenty of opportunities for training. Records confirmed that training was prioritised by the company, and there were a wide range of courses available to the staff team. Staff confirmed that they received a period of induction prior to commencing work. Information in the AQAA stated that since August 2007, all new staff had received the ‘skills for care’ induction booklet. Information in the AQAA provided details about the training programme delivered by the company. National Vocational Qualifications were encouraged, and the information in the AQAA stated that the training programme for staff was in the process of being developed in order to widen the opportunities for ongoing training and development. The information in the AQAA and discussion with the manager showed a commitment to continually develop the training programme for staff so that they were updated in current care practices. Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the residents, and clear policies and procedures help to ensure that the rights and best interests of residents is promoted. EVIDENCE: The manager has been in post since August 2007. She has just completed her registered manager award. It was evident from observations made during the site visit, and from discussions with residents, relatives and staff that she had developed a stable management structure and was providing good support to the staff team. Information provided by the manager in the AQAA demonstrated an understanding of good care practice issues and showed a commitment to Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 Page 22 developing the service further so that residents enjoyed a positive lifestyle in the home. From discussion with residents and staff, it was evident that the manager operated an ‘open door’ policy, and welcomed discussion about ways in which the service can be developed to improve outcomes for residents living there. During the visit, residents and families were seen ‘popping’ into the office to discuss issues. One relative said he felt comfortable in approaching the manager with concerns and that any issues of concern were responded to positively. Staff who were spoken to confirmed that they were in receipt of ongoing supervision, and supervision records supported this, Information provided by the manager in the AQAA provided evidence that policies, procedures and systems were in place to ensure that the safety and welfare of residents was promoted. Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 Page 23 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 X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X 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 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Polebank Hall DS0000005576.V375591.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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