Inspection on 30/07/09 for Poplars

This is the latest available inspection report for this service, carried out on 30th July 2009.

CQC found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Poplars 04/07/07

Poplars 26/07/06

Poplars 27/10/05

Poplars 25/05/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOME ADULTS 18-65 Poplars 123 Regent Road Hanley Stoke on Trent Staffordshire ST1 3BL Lead Inspector Wendy Jones Key Unannounced Inspection 30th July 2009 09:00 Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Poplars Address 123 Regent Road Hanley Stoke on Trent Staffordshire ST1 3BL 01782 209410 01782 269187 stoke.enquiry@caretech-uk.com 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) Delam Care Ltd Manager post vacant Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (6) of places Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Mental disorder, excluding learning disability or dementia (MD) 6 Learning disability (LD) 6 The maximum number of service users who can be accommodated is: 6 18th August 2008 2. Date of last inspection Brief Description of the Service: The Poplars is a six-bedded care home owned by Delam Care Limited, a company owned by Care Tech. The Poplars is in an urban area close to Hanley park and Stoke on Trent College and in close proximity to similar care homes owned by the same company. It is located within a twenty-minute walk to the shopping and leisure facilities of Hanley. The Poplars provides a service to six people of either gender with a learning disability although some may also have mental ill health. The home is one of 3 services all managed by the same manager. The homes have their own core staff members but absences and staff vacancies are covered by staff from the other homes or from other staff from within the company. The people using the service access a range of college courses and undertake social activities and holidays. The organisation has another three homes in the immediate area and between them they have the use of two people carriers and the people using the service contribute to the running of these vehicles. There is one care staff member on duty at all times and the aim is to provide service users with support, encouragement, supervision and monitoring in order to enable them to live as independent a life as possible. Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 5 Information about the range of fees and the costs of the service are not available in the Service user guide. Prospective users of the service and their supporters should contact the provider for this. Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 Star. This means the people who use this service experience good quality outcomes. This was a key inspection site visit carried out by one inspector on 30th July 2009. The visit took approximately 4.30 hours and included discussion with people using the service, staff and management, observation of interactions and the environment. We also looked at care and health records including support plans, staff rosters and training records, medication storage and the administration records, policies and procedures. Before we carried out our inspection we asked the service to provide us with information about it, this is called completing an Annual Quality Assurance Assessment (AQAA). An (AQAA) is a self assessment and is filled in once a year by all providers whatever their quality rating. It is one of the main ways that we will get information from providers about how they are meeting outcomes for people using their service. We also sent out surveys to people using the service and their relatives, staff, health professionals and social workers. We have received 4 surveys from people using the service. Their comments are included in the main body of this report. What the service does well: People using the service say in surveys, “They keep me safe at all times, staff give good advice and encourage me to be more independent.” “They arrange outings and holidays can cook the meals well.” “The home is very good.” “They do look after me well.” Person centred planning is being developed and people using the service are usually included in this. Meetings are held with the people using the service to discuss their support needs, routines, matters that affect them and are important to them. Generally the people using the service are able to choose how they spend their day. Independence is encouraged as much possible. People using the service said, “They arrange outings and holidays can cook the meals well.” “Staff offer good advice and encourage me to be more independent.” People using the service have access the health services and are supported with appointments. Medication is properly stored and administered and where appropriate people are encouraged and supported to self medicate. Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 7 People who use the service say they are happy living at the Poplars. And know how to make a complaint and who to go to if they are unhappy. All bedrooms are single and people using the service are encouraged to personalise them. People have their own keys to the house and bedroom if they want them. People have free access to all areas of the home. Staff training is of a good standard and the number of staff trained to National Vocational Qualification at level 2 and above exceeds the recommended minimum of 50 of the work force. What has improved since the last inspection? What they could do better: The service needs to complete the introduction of person centred planning and ensure that all people who want to be involved in making their own decisions about their lives have the opportunity to do so. People using the service say, “We could do with more staff to be able to go out more often and have more drivers available.” “Need more organised trips out.” “I would like to be more involved with cooking and have more to do outside the home.” “I don’t like gardening or going to the gym.” Homely remedies should be agreed with the prescribing GP or the pharmacist, so that people can be confident that there is no risk to them because of the prescribed medication they take. Staffing levels should be kept under review so that people can be sure that they have staff support when they want it and there social, recreational opportunities are not restricted because of low staff numbers. Staff should also be trained about, The Mental Capacity Act and Deprivation of Liberty. Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 8 The service needs to ensure that the newly appointed manager applies to be registered and approved by us the Care Quality Commission (CQC). If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service have their needs assessed so that they can be confident that the service can meet their needs. EVIDENCE: We have been told in the AQAA that, “Poplars has not had an admission for two years, although should a bed become available and a referral be made we do have paperwork in place that ensures a full and thorough assessment of the persons needs are carried out. The statement of purpose has very recently been reviewed and a far more user friendly version is currently in the development stages. We hope that this pictorial version similar to that of our Service User Guide will be completed by Summer 2009. Further admission procedures have been developed and distributed to allow for a smoother admission process.” We have been provided with evidence that the information given to prospective users of the service and the people that live there is up to date. Efforts have been made to improve the format that the information is in to ensure that it is user friendly and easier to understand. People using the service confirmed that they had received information about the home before deciding to move in and have a copy of the Service User Guide. At the last key Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 11 inspection we recommended that the fee range and charges for the service are included in the Service User Guide, this remains a recommendation of this report, so that people using the service know what they are expected to pay for. People using the service have all lived at the home for at least two years. We looked at a sample of assessment information this is called case tracking and saw that assessments of the individuals needs are carried out prior to agreeing tat the service can meet them. Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can be more confident that the support plans being developed are up to date and provide staff with the information they need to support them properly. EVIDENCE: Information in the AQAA tells us that, “The support plans that we currently have in place at Poplars are in need of an update and the format that we use is being reviewed to ensure that support plans are more accessible. This reformat will be done using a person centred approach and will be in cooperation with the individual concerned.” We looked at two people’s care plans and saw that the service is in the process of changing the care and support plans as stated in the AQAA. The model being implemented is intended to be more person centred to address the individuals needs, aims and goals. We talked to people using the service about Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 13 their support plans, they confirmed that they are spoken to about them and have also been involved with the risk assessments that are carried out. As with the support plans the service is intending to review all of the risk assessments. We saw a 24 hour plan of care that has been started for one person and noted that it provides good information about the individual’s daily routine and needs. We saw that the individual had been involved in developing their plan. But we looked at another example, where we couldn’t tell if the individual had been involved with its development. We spoke to people about the one to one time they have and they confirmed that these meetings are usually held regularly. We asked if one person who has a hearing impairment has been involved in the one to one discussion because the records show that this person isn’t. We have been told that this person is offered the opportunity but doesn’t like to participate in them. We were concerned at the last key visit that staff had not had training to effectively communicate with this person. We have been told that since then, 3 staff have received a one day training course in British Sign Language, additional training is planned. We have been satisfied that the recommendations made at the last key inspection about meeting the diverse needs of people using the service have been acted on. Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are able to choose the activities and lifestyle they want to lead. But may need more support to make informed decisions. EVIDENCE: We spoke to people about the things they do during the day and the evening. One person told us that they go to college for two days a week and other confirmed that she also did. We have also been told that one person has applied for a voluntary position with the local charity, and hopes to be appointed once the necessary checks have been carried out. Most people in the home have some level of independence both in and out of it. The level of independence can vary dependent on their mood and health. We observed one person going out to the pub for the evening with a peer from another of the services. We have been told that people are going on holiday Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 15 together in August. We think that the service could do more to promote person centred planning in this area. This means that the service should always try to plan events based upon individual needs, wishes and goals, rather than planning group activities or events. People said in surveys that, “They keep me safe at all times, staff give good advice and encourage me to be more independent.” “They arrange outings and holidays can cook the meals well.” “We could do with more staff to be able to go out more often and have more drivers available.” “Need more organised trips out.” “I would like to be more involved with cooking and have more to do outside the home.” “I don’t like gardening or going to the gym.” We talked to people using the service about meals and their involvement in domestic chores. One person said. “I like to be involved in cooking food and shopping for it,” but another said, “I don’t like having to prepare vegetables at mealtimes.” And while we were at the service this person asked the acting manager if she had to be involved in something she didn’t want to do. The manager and the operational manager reassured her that she did not have to engage in activities she did not want to. Menus are agreed at weekly menu planning meetings. People using the service told us that they can eat what they want to and we observed that they have free access to the kitchen. Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can be sure that the service will support them to access health services and manage their medication safely. EVIDENCE: We saw that the service has introduced health action plans for everyone, “A Health Action Plan (HAP) is an individual plan, belonging to a particular person that explains that persons health needs. It also describes what has to happen for those needs to be met.” We saw in other records that people using the service are supported to access health services including the GP, dentist and specialist services. We saw in the records we looked at that a Consultant and Social Worker are very happy with the support one person is receiving by the service. They have regular meetings to discuss the needs of this person and have been satisfied that the service has acted on the recommendations they have made. Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 17 We looked at how the service manages medication. One person self medicates so we spoke to her about how she has been supported to do this. She said, “I have been helped to have my own medication and have a secure tin to store it in. I keep my bedroom door locked at all times so no-one else has access to it. I have occasionally forgotten to take medication but I have spoken to the deputy manager about this and he has helped and advised me. I know to go to him if I have any difficulties with my medication.” We discussed the types of medication the individual is prescribed and noted that she had an understanding of the why she takes the medication and what it is for. We looked at a sample of medication administration records (MAR). We saw that medication has been signed for properly. We looked at how medication is stored and saw that the service has appropriate storage facilities. We saw that no one has a homely remedy list agreed with the GP. We talked to the acting manager about homely remedies generally. We have been told that if individuals purchase over the counter medication staff will contact NHS direct or the GP to confirm that the medication can be safely taken by them. We have recommended that the manager accesses the latest guidance we have provided to care homes relating to Homely remedies and act to improve in this area. Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can be confident that the service has robust procedures in place to address and report any complaints or allegations and to ensure that people using the service are protected. EVIDENCE: The service told us in the AQAA that, “The complaints policy is formatted in an easy read version and is available to people within their individual service user guide and a copy is also on display in the entrance hall to the home. This policy is also available to family and friends of service users and visitors to the home. Staff have updated their training in the protection of vulnerable adults.” We saw that the complaints procedure has been revised and is in a more user friendly format. People using the service told us that, “If I am concerned I will tell the staff, I now they will listen to me.” Another said, “I was not happy about some of the decisions the company had made about staffing, so I wrote to them, they have met with us to explain why they have done things and I understand it better now.” People confirmed in surveys that they know how to complain and who to go to if they have any concerns. Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 19 We spoke to the acting manager about safeguarding, mental capacity and deprivation of liberty guidance and training. We have been told that all staff have received safeguarding training, the acting manager has received mental capacity and deprivation of liberty training. Additional training is planned for other staff. The acting manager stated that a deprivation of liberty referral is not relevant for people living at the Poplars at the moment. We have not received a complaint or have been aware of any safeguarding referrals since the last key inspection visit the acting manager confirmed this. The service has not employed any new staff since the last key inspection visit, so recruitment records have not been checked during this visit. The service has told us in the AQAA that, “Should a vacancy arise and a candidate be offered the post we ensure that prior to commencement of employment a number of different checks are carried out. These checks include 2 satisfactory references and an enhanced CRB check. Should references be received prior to the CRB being complete then we will request a POVA which will allow an individual to work shadowing a member of the staff team. This is risk assessed.” We the Care Quality Commission allocate larger organisations such as Caretech, a Provider Relationship Manager, who also looks at how the organisation recruits staff. The last report about this states, “The recruitment practise has improved.” Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can now be confident that that the service has continued to make improvements to the environment. This ensures they live in a well maintained and comfortable home. EVIDENCE: We didn’t carry out an audit of the environment during this visit, we have been told in the AQAA that plans are in place to improved the environment in all of the homes. The stair carpet is to be replaced and the hall and stairway is going to be redecorated. The lounge was redecorated and refurbished last year. People using the service said that they have been asked about improvements to the home. One person said she would like her bedroom redecorated as it hadn’t been done for some time we spoke to the manager about this. The service has a first floor bathroom and toilet and a ground floor shower and toilet. There is a separate dining room which lead on to the kitchen both areas Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 21 are compact. The home shares a laundry with two other homes located in the shared yard/garden. Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can be sure that staff have been properly trained and have the skills they need to support them. EVIDENCE: The service has one member of staff per shift with additional management hours, other staff can be provided for planned events. The shift patterns are from 7:30am-4pm and 3.45pm-10pm. Sleep in. The service has three care staff plus the acting manager who has responsibilty for two other houses. We are told that the service has no staff vacancies at the moment. We have highlighted concerns about staffing levels in past reports and people using the service have told us in surveys that, “The home could do better by having more staff available so we can go out more, and more staff who can drive.” The acting manager has spoken to us about the possibility of a “mid shift”. Which is an extra member of staff rostered to be on duty at times when they can support people who use the service to go out, if they want to. Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 23 We did not look at recruitment records during this visit as no new staff have been employed since the last inspection visit. Discussion with people using the service and staff made us aware that although no new staff have been employed there have been some changes to the staff team. One person confirmed that they had not been happy about the move of long standing staff to another home. But had been assured that even though staff had been moved there was no reason they could not maintain contact, the individual was happy with this. We, the Care Quality Commission(CQC) allocate larger organisations such as Caretech, with a Provider Relationship Manager, who also looks at how the organisation recruits staff. The last report about this stated, “The recruitment practise has improved.” We saw that the staff have access to a range of training opportunities and the numbers of staff trained to National Vocational Qualification(NVQ) at level 2 or above is good. But training is needed on the Mental Capacity Act and Deprivation of Liberty to be certain that staff have a full understanding of the implication of this new legislation. During this visit we spoke to one member of staff who confirmed that supervision sessions are regularly provided and training is up to date. This support worker is not usually allocated to Poplars, but is familiar with the people living there, they confirmed this. We saw records of staff meetings. Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service have confidence in the management arrangements at the service but would benefit from being allocated a permanent manager who is registered and approved. EVIDENCE: The service does not have a manager who has been registered and approved by us. The previous manager left approximately 15 months ago, a replacement manager was recruited but we have been notified that the position is now vacant again. We have spoken and written to the provider about the need to have a manager who is registered with us. We wrote in September 2008 and again on the 9 February 2009 about the organisations failure to ensure that a manager had applied to us to be approved. During this visit we have been informed that a new manager is to start work at the home. In the interim a Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 25 deputy manager is being supported by a manager of one of the other organisations homes. The current deputy has been moved from one of the other homes in the area. We have received a completed AQAA but we had to remind the service to send the AQAA to us in within the stated timescales. We saw that the AQAA is detailed in some areas but not in others. The AQAA states that the service has relevant policies and procedures in place but has not told us when they have last been reviewed. This means we cannot be sure that they are all up to date. It does tell us how the service has made improvements and how it intends to continue to improve. We have been told in the AQAA that the equipment in the home is serviced regularly and is in a good state of repair. We didnt check this during our visit. People using the service said that they are usually involved in decision making within the home, but we recommend that when the service carries out audits of the service and arranges for visits to be made to the home to assess the quality of service it provides. That people using the service are informed of the outcome of these audits/visits, so that they can be actively involved in the services plan to improve. We saw evidence that monthly monitoring visits are made to the home. Risk assessments have been carried out for individuals and generally, the assessments we saw show that they have not always been reviewed regularly. The acting manager confirmed that as with the support plans all risk assessments are in the process of being reviewed. People told us that they manage their own money; some have more support than others. Each person has a bank or saving account. The organisation has strengthened its Quality Directorate this has resulted in quality audits taking place more regularly in services. We saw evidence that action plans that have been developed based upon the outcome of the audits. At the last inspection people using the service had the opportunity to be involved in local forums to discuss matters affecting them and their peers. A representative from each of the homes attended the meetings. The organizations commitment to listening to people using its service was recognized. But since the last visit these meetings have not been taking place as regularly. The Operational manager stated that they are to be reintroduced. Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 1 X 3 2 X 3 X Version 5.2 Page 27 Poplars DS0000064016.V376529.R01.S.doc 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. 1 Standard YA37 Regulation 9 Requirement The provider should ensure that the new manager applies to us to be registered as a fit person to manage the service. Timescale for action 22/11/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard YA6 YA1 YA20 YA32 YA33 Good Practice Recommendations The service should continue with its intention to implement the Person Centred Plans, for each individual. The service user guide should include the range of fees and any additional costs service user can expect to pay; this includes cost of the mini buses. The service should make necessary changes to medication procedures to reflect the most recent guidance about how homely remedies should be managed. The service should ensure that staff have received training about the Mental capacity Act and Deprivation of Liberty. The service should continue to keep staffing levels under review, so that people can be certain that sufficient staff are provided to enable them to go of the home when they want to. The service should re introduce the forums for people DS0000064016.V376529.R01.S.doc Version 5.2 Page 28 6. Poplars YA39 7. YA40 using the service to be certain that they have a voice. Policies and procedures should be regularly reviewed to ensure that they are up to date and reflect current good practise. Poplars DS0000064016.V376529.R01.S.doc Version 5.2 Page 29 Care Quality Commission Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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