Care Home: Polefield Nursing Home

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What the care home does well There is a calm and relaxing atmosphere in the home, and visitors were made to feel welcome. Most feedback from residents and their families was that they were happy with the care and support provided by the staff team. One visitor said, " It`s absolutely brilliant. I would recommend (Polefield) to anyone. Especially how staff treat the people living here. It`s always clean and there`s always someone about. When anything happens, they always ring you and keep you informed, and if I have a concern they deal with it". There were a lot of positive comments from residents about the home. One resident said, " Everyone is very friendly and I like the food. It`s flexible and they let me get on with myself. Staff always ask me if I`m alright, I`m happy it`s my home". Another resident said, " Everything is nice here. The meals are quite good, and the people." "Staff are very good and they do their best". Staff were seen talking to residents in a polite and courteous manner, and responded quickly to any requests for help. Visitors to the home were made to feel welcome, and one visitor said that there was always a member of staff around to help and answer any queries. During the visit, the home appeared clean and tidy throughout. There is a well-established `link nursing` scheme, where members of staff have responsibility to keep up to date with key aspects of nursing practice, and to update staff with any new information. This seemed to be working well, and care staff felt confident in approaching nursing staff if they had any concerns or queries regarding practice issues. This system was useful in ensuring that all staff were kept up to date with good practice. What has improved since the last inspection? There have been general improvements to the physical building and refurbishment is ongoing to ensure that residents and their family benefit from pleasant surroundings. The activity programme has improved, and there is a member of staff appointed to organise a programme of events. What the care home could do better: There is information about the home, but this should be made available to prospective residents and their relatives, as well as those residents already living in the home. This will help people when they have to make a decision about their care arrangements, and it will also inform residents living in the home of the kind of service they can expect to receive.Regular reviews were taking place, but there was very little information about the views of residents and their families, and no evidence to confirm that they had been involved in the review of their individual care plan. The recordings should be in sufficient detail and include the signatures of those involved where possible to show that a genuine attempt has been made to include residents and their family in the review of care needs. Regular audits of the medication in the home would be useful in making sure that good practice was carried out consistently by all staff, and to ensure that medication procedures were being followed at all times. This would ensure that if any shortfalls were identified, these could be addressed at an early stage. A training plan needs to be in place so that the manager can monitor staff training needs and ensure that the skill mix of staff is appropriate to meeting the needs of the residents in the home. The manager`s plans to obtain the views of families and residents will be helpful to ensure that the manager and staff gain insight into how people using the service feel about the care and support they receive. This will help them to see things from the resident and family perspective. For example, one relative felt that some of the residents with high dependency needs were sometimes forgotten when activities were being arranged. Obtaining these kind of views and comments should have a positive effect in developing a service that meets the needs of residents in the home. CARE HOMES FOR OLDER PEOPLE Polefield Nursing Home 77 Polefield Road Blackley Manchester M9 7EN Lead Inspector Ann Connolly Unannounced Inspection 16:30p 30 January and 8 February 2008 th th 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 Polefield Nursing Home DS0000021655.V349173.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. Polefield Nursing Home DS0000021655.V349173.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Polefield Nursing Home Address 77 Polefield Road Blackley Manchester M9 7EN 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) 0161 795 4102 0161 740 4903 Rosewood Care Services Limited Ms Kay Rooney Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (38), Physical disability (2) of places Polefield Nursing Home DS0000021655.V349173.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users requiring nursing care shall be 37 and the maximum number of service users requiring personal care only shall be 3. All service users are aged 60 years and over except two named service users requiring care by reason of physical disability. Registration is subject to compliance with the minimum nursing staffing levels indicated in the Notice previously served in accordance with Section 25 (3) of the Registered Homes Act 1984 issued on 20 December 2000. 6th December 2006 Date of last inspection Brief Description of the Service: Polefield Nursing Home is a care home providing nursing care and accommodation for a maximum of 40 older people. The home is able to accommodate 37 older people assessed as requiring nursing care in addition to 3 older people assessed as requiring personal care only. The home is situated in a residential area in the Blackley district in the North of the City of Manchester. The home is well served by public transport links and within easy reach of Manchester, Rochdale and Oldham Centres. The home is close to local facilities, shops, Boggart Hole Clough Park and other cultural and recreational facilities. The home is a purpose built care home that provides accommodation on two floors. The second floor is used for office accommodation and storage. The home has off road parking for a number of vehicles. The main entrance to the home has low ramp access and is accessible to wheelchair users. A passenger lift provides access to all levels of the home. Fees range from £373.54 to £482.10. Polefield Nursing Home DS0000021655.V349173.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 an unannounced inspection that took place over two half days. One visit took place on the evening of 30 January 2008 and the other visit was on the morning of 8 February2008. During the site visit a selection of records, care plans, policies and procedures were examined. Discussions took place with the deputy manager, staff working in the home, and some relatives who were visiting. Prior to the inspection, questionnaires were sent out to the people who live in the home, asking them to comment on how the home is run and managed, and for their views about how the staff supported them. None of these were returned. Staff surveys were also sent out. Some of these were returned and the comments have been included in this report. 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 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. The manager had recognised what improvements could be made and was taking steps to address the issues. Since the last inspection visit, which took place on 6 December 2006, the Commission for Social Care Inspection has received no concerns about this service. 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 one complaint, which was not upheld. Polefield Nursing Home DS0000021655.V349173.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: There is information about the home, but this should be made available to prospective residents and their relatives, as well as those residents already living in the home. This will help people when they have to make a decision about their care arrangements, and it will also inform residents living in the home of the kind of service they can expect to receive. Polefield Nursing Home DS0000021655.V349173.R01.S.doc Version 5.2 Page 7 Regular reviews were taking place, but there was very little information about the views of residents and their families, and no evidence to confirm that they had been involved in the review of their individual care plan. The recordings should be in sufficient detail and include the signatures of those involved where possible to show that a genuine attempt has been made to include residents and their family in the review of care needs. Regular audits of the medication in the home would be useful in making sure that good practice was carried out consistently by all staff, and to ensure that medication procedures were being followed at all times. This would ensure that if any shortfalls were identified, these could be addressed at an early stage. A training plan needs to be in place so that the manager can monitor staff training needs and ensure that the skill mix of staff is appropriate to meeting the needs of the residents in the home. The manager’s plans to obtain the views of families and residents will be helpful to ensure that the manager and staff gain insight into how people using the service feel about the care and support they receive. This will help them to see things from the resident and family perspective. For example, one relative felt that some of the residents with high dependency needs were sometimes forgotten when activities were being arranged. Obtaining these kind of views and comments should have a positive effect in developing a service that meets the needs of residents in the home. 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. Polefield Nursing Home DS0000021655.V349173.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 Polefield Nursing Home DS0000021655.V349173.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, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is information about the home to help people to make an informed choice about their care arrangements. Pre- admission assessments ensured that prospective residents can be confident that their needs will be met when they are offered a place in the home. EVIDENCE: This service has a Service User Guide and a Statement of Purpose that provides details about the facilities, and information about the home. This ensures that all prospective, and existing people living in the home have useful information about the services offered. Prospective people wishing to use the services can make an informed choice about their future care arrangements. A copy of this guide was not made readily available in the reception area, and people who were spoken to were not fully aware that this information was Polefield Nursing Home DS0000021655.V349173.R01.S.doc Version 5.2 Page 10 available. The senior member of staff explained that copies often went missing from the reception area. It was recommended that a supply was made available for existing and prospective residents. Three care plans were looked at during this visit, and all of them contained a pre admission assessment. The staff who were spoken to explained that the manager or a senior member of staff always visited any prospective resident in their own home, or in hospital, so that they could explain what the service could offer and assess whether the home could meet their needs. The assessment undertaken by the manager was supplemented by the multidisciplinary assessment which was carried out by the care manager from the authority responsible for funding the placement. The information from these two assessments was used to develop a comprehensive care plan, which provided staff with the information they need to meet individual care needs. Intermediate care is not provided. Polefield Nursing Home DS0000021655.V349173.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. The health and personal care received by residents is based on individual needs. Care plans provided details of residents care needs and the interventions required to meet needs. EVIDENCE: Three care plans were looked at during this visit. These contained details of health and personal care needs, optician, dental, hearing and outpatient appointments. There was evidence that the care plans were reviewed monthly. However, this consisted of just a date and signature, with no written record of what was discussed, and no evidence that residents and their families were involved in the process. It was recommended that reviews should be documented and linked to the daily reports so that staff are kept informed of issues and concerns and are alerted to any changes made in the care plan. One relative said she felt that staff kept her informed of any changes in care needs, but that she could not recall being involved in a formal review of care needs. She said she felt this would be a helpful process so that any concerns Polefield Nursing Home DS0000021655.V349173.R01.S.doc Version 5.2 Page 12 could be discussed. She said that overall she felt happy with the care received by her mother and said, “The senior staff seem to know what they are doing”. Another relative praised the staff team, and felt they responded well to any care needs her mother had, She said she felt confident in the staff at the home. During the visit there was a calm and relaxed atmosphere. Staff were seen attending to residents in a sensitive and caring manner. One resident said, “There’s no place like home, but it’s lovely here, the staff look after us well”. Appropriate risk assessments were in place, and records of nutritional management. There were records of visits made by a range of healthcare professionals, which showed that the staff in the home support residents to access healthcare services when it becomes appropriate. Information, provided by the manager in the Annual Quality Assurance Assessment (AQAA), identified a number of areas which are planned for improvement this next year. These included reviewing the care plans and improving medication training for staff. This provided evidence of a service that is committed to improving systems and procedures in the home to ensure the well being of residents living there. Medication and systems were looked at during this visit. The medication was stored appropriately. The medication administration records (MAR) were up to date, and only one instance of a gap in signing was noted. It is important that staff make sure they sign the MAR sheets immediately after giving the medication out. Some stock levels had not been transferred onto the MAR sheets. This must be done so that the records are an accurate reflection of the medication in stock. It was recommended that regular audits of medication take place, so that any shortfalls are identified and addressed at an early stage. Polefield Nursing Home DS0000021655.V349173.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): 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 social activities, and daily life in the home and are encouraged to maintain links with their family and friends. This allows residents to exercise as much choice and control over their lives as they can. EVIDENCE: During this visit there was a range of activities going on and staff were seen spending quality time with residents, talking to them and supporting them to join in with activities. Residents who were spoken to said that they had plenty of opportunities to join in with events. One resident said she liked it when the entertainer came in. Another resident said, “There’s always something going on, but I don’t always join in”. Other residents were seen making way to their own rooms to watch television in privacy or read newspapers. The staff who were spoken to all said that there was a lot of emphasis on ensuring that residents were offered a range of activities. Two members of staff were enthusiastic about the activity programme and listed recent activities that had taken place, such as health and beauty, one to one games, and outside entertainers. The activities organiser was on duty during this visit. Polefield Nursing Home DS0000021655.V349173.R01.S.doc Version 5.2 Page 14 She tries to get round to most of the residents to arrange suitable activities. One visitor expressed some concern that the activities focused on more able people, and did not cater for those residents who spent a lot of time in their room or in bed. Information in the AQAA demonstrated that social and leisure activities were considered to be an important part of life within the home. The AQAA stated that there are plans to review the social care plans, to avoid any resident from being excluded. One of the ways they state they intend to develop is by obtaining views of families, residents and staff by arranging meetings for individuals to share their ideas. Visitors were seen calling into the home during the two visits. Staff appeared to make visitors welcome. One visitor said there were always staff around to help. Residents could have their meal served in the dining room or their own bedroom. The meal served during the visit appeared well presented and wholesome, and residents indicated that they enjoyed their meal. The cook confirmed that choices were available. Polefield Nursing Home DS0000021655.V349173.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. The home provided a safe environment for residents. Polices and procedures are in place to ensure that residents are protected from abuse. EVIDENCE: A copy of the complaints procedure is displayed in the entrance to the home. There were just three complaints recorded. Two were in 2003 and the last one was in September 2007. This was investigated appropriately and the response and action taken was recorded. The manager showed an understanding of the importance of recording all complaints no matter how trivial. This was an area where she felt the organisation could improve, which had been identified in the AQAA. There was also an acknowledgement that further improvements could be made in monitoring complaints, and for this to be used as an exercise to improve the quality of the service. Residents and their families expressed confidence in raising issues of concern with the manager, and said they were confident that any complaints would be taken seriously. Most staff who were spoken to during this visit demonstrated a good understanding of issues surrounding abuse. Where some concerns were identified, this has been addressed under the staffing section of this report in standards 27-30. Staff were aware of policies and procedures on safeguarding, and information on staffing files showed that training in safeguarding adults was provided. From the records, it was not possible to Polefield Nursing Home DS0000021655.V349173.R01.S.doc Version 5.2 Page 16 determine how up to date training in safeguarding was for all staff members. The manager is aware of this and stated that she was currently in the process of developing a matrix for staff training, which will enable her to monitor training and identify when updates are due. Information in the AQAA states that training for staff will be prioritised in the forthcoming year. Polefield Nursing Home DS0000021655.V349173.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. The home is pleasant and comfortable, and provides residents with a relaxing environment in which to live. EVIDENCE: During the two visits made to the home, the environment was clean and tidy with no unpleasant odours. There are two floors, each with a sitting room, dining room, and bathing and shower facilities. Bedrooms were clean and tidy, and many were personalised, reflecting individual tastes. A number of residents had brought their own television and small items of furniture, pictures and ornaments. Many of the rooms appeared cosy and comfortable. The proprietor visits the home most days and arranges for maintenance when necessary. Information in the AQAA demonstrates that the manager is keen to Polefield Nursing Home DS0000021655.V349173.R01.S.doc Version 5.2 Page 18 continue with improvements to the environment. New carpets had been provided for some bedrooms. Residents spoken to said they were happy with their personal space. One resident said he felt relaxed and comfortable, and said he could go to his room for ‘peace and quiet’ whenever he wanted to. Polefield Nursing Home DS0000021655.V349173.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. Good recruitment procedures, and training programmes for staff are in place. Residents using the service can be confident that staff receive appropriate support and training, to ensure that they have the right skills to help them to meet the needs of the people they provide care and support to. EVIDENCE: During this visit, there appeared sufficient staff on duty to meet the needs of the residents in the home. There was one qualified nurse, two care staff and a domestic on each floor. At the time of this visit there were 28 residents living in the home. Staff were observed engaging in meaningful conversations and responded quickly to any resident asking for support. Information in the AQAA showed that the home prioritised training. Staff files provided evidence that training was ongoing. It was difficult to see a full overview of training, however, the manager stated that she was currently developing a staffing matrix to help her to monitor training, identify when updates are needed, and any gaps in staff knowledge and skills. There is well-established ‘link nursing scheme’ which has been set up by the manager. The purpose of this is to reinforce good practice on a day to day basis, and to ensure that staff are kept up to date with current good practices. A key area of practice is allocated to individual nurses in the home. Topics Polefield Nursing Home DS0000021655.V349173.R01.S.doc Version 5.2 Page 20 include peg feeding, catheter care and wound care. Each individual nurse has the responsibility of keeping up to date with a specific area of practice, with the follow on responsibility of updating the remaining staff team of changes, and to provide the updates or training as required. If the ‘link nurse’ delivers training to the staff team, this is followed up by a self-assessment questionnaire. This enables the ‘link nurse’ trainer to assess staff knowledge after the training and establish if further training is needed. From discussion, it was evident that a number of these training sessions had been organised in the home, however, they were not recorded on a training matrix or on individual files. It was recommended that all training was recorded to demonstrate that staff have been provided with the knowledge and skills to carry out their job. Information provided in the AQAA stated that over 50 of staff have, or are working towards NVQ level2 or above in care. Staff who were spoken to confirmed that they had access to training and development opportunities. There is a recruitment policy in place. This provided information of a clear and structured process detailing the checks and procedures which need to be followed so that residents can be sure that all staff employed are suitable for the position they hold. Three staff files were examined and contained the appropriate paperwork and documentation as required by regulation. However, although one file had two references, these were not from the last employer. It was explained that as this person came from overseas, it had been difficult to obtain one. When this happens, detailed explanations should be recorded, with evidence of actions taken to obtain references. This is essential, so that residents can be fully confident that their well-being is protected. Files examined contained Criminal Record Bureau (CRB) checks. It was evident from the information examined, that the manager was regularly auditing files, and was currently in the process of developing staff profiles to include all training certificates, staff photographs, and health declarations. One of the staff on duty experienced difficulty in expressing herself in the English language. One resident said, “ Sometimes it’s difficult to understand one or two of the staff who are not English, but they’re lovely, and we get there in the end”. Some residents with communication difficulties may experience a greater problem than others in communicating with staff who do not speak English proficiently. It is essential that the skill mix of staff on duty in regard to their ability to communicate verbally and in written English must be adequate for the tasks they need to perform, so that they can meet the individual needs of people in the home and do not place residents at risk. The deputy manager explained that staff with limited English are not responsible for providing personal care, and are always supported by other staff who can assist them. Polefield Nursing Home DS0000021655.V349173.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. Appropriate policies and procedures were in place, so that people can be confident that their safety, health and well-being are protected. EVIDENCE: Since the last inspection the manager has worked towards improving the service. There were no requirements made at the last inspection, and none were made during this visit. Staff who were spoken to said that they found the manager approachable, and that they felt confident in raising any issues of concern. Staff confirmed that they were in receipt of regular supervision. In the self-assessment document, completed by the manager before the inspection, she identified that it was necessary to continually improve staff training and supervision programmes. Polefield Nursing Home DS0000021655.V349173.R01.S.doc Version 5.2 Page 22 Information in the assessment document provided evidence that all policies and procedures in the home had been updated and reviewed. This was confirmed by the manager. Regular testing and auditing on all aspects of Health and Safety were being carried out. Polefield Nursing Home DS0000021655.V349173.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 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Polefield Nursing Home DS0000021655.V349173.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. 1 Refer to Standard OP1 Good Practice Recommendations Information about the home should be made available to anyone interested in the service, so that people can make an informed choice about their future care arrangements, and be fully informed about what the service can offer. Information from reviews should be documented to demonstrate that residents and their families have been involved in the process, and to provide clear information to staff on any issues of concern, or changes in care needs. A medication audit should take place regularly to ensure that systems are in place to ensure residents receive medication safely. All staff training should be recorded on a training matrix and in individual files to demonstrate that staff have received appropriate training for the work they do. DS0000021655.V349173.R01.S.doc Version 5.2 Page 25 2 OP7 3 OP9 4 OP30 Polefield Nursing Home 5 OP30 The skill mix of staff (including their command of the English language both verbal and written) must be at an adequate level so that the care and safety of residents is not compromised. Staffing skills should be monitored to ensure that the diverse needs of residents are met. Polefield Nursing Home DS0000021655.V349173.R01.S.doc Version 5.2 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Polefield Nursing Home DS0000021655.V349173.R01.S.doc Version 5.2 Page 27 - 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. 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