Inspection on 12/07/05 for Popham Court

This inspection was carried out on 12th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Popham Court 17/04/07

Popham Court 06/01/06

Popham Court 11/01/05

Popham Court 08/06/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Popham House Courtland Road Wellington Somerset TA21 8NE Lead Inspector Caroline Baker Announced 12 July 2005 th 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 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. Popham House D53-D02 S16052 Popham House V230433 120705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Popham House Address Courtland Road, Wellington, Somerset, TA21 8NE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01823 662513 01823 669216 Somerset Care Ltd Hazel Anne Jones Care Home with Nursing 37 Category(ies) of Old age (37) registration, with number of places Popham House D53-D02 S16052 Popham House V230433 120705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Registered for seven places for personal care. Date of last inspection 11th January 2005 Brief Description of the Service: Popham House is registered with the Commission for Social Care Inspection (CSCI) as a Care Home to provide general nursing care and personal care for a total number of 37 people over the age of 65 years. Somerset Care Ltd owns the home and the Registered Manager is Hazel Jones. In addition there are 25 beds funded by Social Services of which 4 are interim (Nursing Block Contract) allocated for delayed discharges from acute beds and managed by the Adult Social Work team at the local hospital. One of the 25 beds is a respite nursing bed funded by social services. The home is a short distance from Wellington town centre where there are a range of shops, banks and other facilities. The home shares the grounds with another Somerset Care Home, The Court, registered with the CSCI for personal care only. Adjacent to Popham House is a Community Park, a facility that can be used by service users. It has level access and has been suitably adapted to accommodate the client group. Catering and laundry are undertaken at The Court. The home has both a small kitchen and domestic style laundry facilities on site. A passenger lift is available for access to the second floor. Popham House D53-D02 S16052 Popham House V230433 120705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last inspection was unannounced and took place on 11th January 2005. At that inspection one requirement was identified. This announced inspection took place over one day from 08:45 (6.75 hours) and was conducted by Caroline Baker. At the time of this inspection the requirement identified had been complied with. Thirty-one service users were residing at the home of which two were receiving personal care only. Staffing levels were above minimum staffing levels on the day of inspection. An assessment of the premises took place where a selection of bedrooms and communal areas were seen. At least eighteen service users were spoken with. Hazel Jones, the registered manager, was available throughout the inspection. Throughout the day the inspector was able to observe interactions between staff and service users and was able to join service users for lunch. Records relating to the care of the service users, staff and health and safety were examined. The inspector would like to thank service users and staff for their time and help during the inspection. What the service does well: Popham House provides a well-maintained, secure and environment, which meets the needs of the current client group. comfortable Service users were observed using all communal areas and appeared comfortable and relaxed in their environment. Service users spoken to stated that they liked their bedrooms and were happy and felt safe at the home. Each room has a “Do Not Disturb” sign, which can be used for extra privacy. Service users were well attired and looked well cared for on the day of inspection. Service users nursed in bed looked comfortable and well cared for. Service users praised the food. A good choice of wholesome food was given. Popham House D53-D02 S16052 Popham House V230433 120705 Stage 4.doc Version 1.30 Page 6 Service users praised the staff. One comment received was “they are all kind and caring”. Relatives spoken to indicated their satisfaction at the provision of care at the home. Staffing numbers and the skill mix of staff were sufficient to meet the dependency needs of current service users on the day of inspection and exceeded minimum staffing levels. Staff spoken with stated that they felt well supported and happy working at the home. Staff training was well documented and the provision of training for staff was very good. Staff looked and acted in a professional manner. What has improved since the last inspection? What they could do better: Provision of alternative meals should be readily available where possible at all times to meet service users needs unless stated otherwise in the statement of purpose. Action was taken on the day of inspection to ensure this. Service users or where possible must have input into their individual care records at the pre-admission assessment stage and then at reviews to evidence their agreement with the written record. The inspector remains satisfied that the home is suitable for its stated purpose and was reassured that action will be taken to address the issues raised. 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. Popham House D53-D02 S16052 Popham House V230433 120705 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Popham House D53-D02 S16052 Popham House V230433 120705 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 4, and 5. NMS 6 is not applicable. Service users are provided with the information they need to enable them to make an informed choice about moving to the home. The home was able to demonstrate that service users are fully assessed prior to admission to ensure their needs can be met. The home would be able to introduce prospective service users to the home prior to admission. EVIDENCE: The home had a current Statement of Purpose at the home for service users and visitors to access. All service users are given a copy of a guide to the home. Service users spoken with at inspection confirmed this. Evidence was seen in the most recently admitted service users care plans sampled that pre-admission assessments had been gained to ensure the home could meet their needs. Service users are able to visit the home at any time prior to admission. Popham House D53-D02 S16052 Popham House V230433 120705 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, and 10 Each service user had an individual plan of care. The home’s care planning system demonstrated that care plans were kept under constant review. Evidence that service users agreed with their written care plan and risk assessments was not seen. Service users have access to health care professionals expertise to meet their individual needs. Service users were protected by the homes high standard procedures in regard to the receipt, administration, recording and disposal of medications. Service users were treated with kindness and respect. EVIDENCE: Five individual service users care plans were examined and the individual service users were met as part of a case tracking process. The care plans were comprehensive. Individual care needs plans contained detailed actions to be taken by care staff to assist with or deliver the care. All care plans reflected current individual care needs. Generic, falls, pressure sore, nutritional and manual handling risk assessments were in place. Popham House D53-D02 S16052 Popham House V230433 120705 Stage 4.doc Version 1.30 Page 10 Evidence was seen that individual service users had been seen by and had access to a chiropodist, optician, dentist, and GP. Pressure relieving equipment was being used appropriately. Wound care was well detailed. One service user had pressure ulcers, which had developed prior to admission. There was no evidence in the care plans sampled, that service users had input into their care plans. This is required so that service users can have an opportunity to agree their care needs plan. Medication systems were examined to include records of receipt, administration, recording and disposal. Good practice was seen throughout. Some service users had responsibility for their own medication, maintaining and encouraging independent living. Each bedroom sampled had provision of a lockable space to store medication in. Service users were treated and addressed appropriately by staff. Care plans reflected preferred names. Service users can lock their bedroom doors from the inside if they wish for extra privacy, and staff would be able to access the rooms from outside in an emergency. Staff were seen and heard to knock on doors before entering service users rooms. Service users spoken to indicated that the staff always treated them with respect. The majority indicated that they felt well cared for, liked living at the home, that the staff treated them well and that their privacy was respected Popham House D53-D02 S16052 Popham House V230433 120705 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, and 15. Service users benefit from a range of activities provided by the home to suit their individual choices and needs. The home is open to visitors at any time and encourages service users to access the local community. Service users individual choices and needs dictate the routine of the home. Service users are offered a choice of nutritious well-balanced menus promoting their health and well being. EVIDENCE: Activities such as, reminiscence, flexercise, music, films, quizzes, bingo, and crafts, are offered to all service users on a weekly basis. The home has access to a mini bus with a dedicated driver. Trips are organised on a regular basis. Service users spoken to at inspection were happy with the activities provided. On the day of inspection service users were seen watching old films and reminiscing. Popham House D53-D02 S16052 Popham House V230433 120705 Stage 4.doc Version 1.30 Page 12 Each service user had an individual record of social activities they had joined in with evidencing that all service users have a chance to join in. The home has a visitor’s book, which indicated many visitors to the home at varying times. Service users told the inspector that their families and friends were made welcome at the home. One visitor stated that their relative had “wonderful care” and that the staff “were very good” and that they were “always made welcome”. It was evident through comments received from service users that they had a choice of daily living. One service user told the inspector “they let me do what I want”. The inspector was able to join service users for lunch. It was pleasing to note that service users had been given a choice of meal. There were four desserts on offer. The food was well presented and tasty. The majority of service users spoken to stated that the food was always good. Everyone in the dining room appeared to enjoy their meals. The atmosphere was happy and unhurried Hot and cold drinks were available throughout the day and service users told the inspector that they could have anything they ‘fancy’ at any time of day. One service user did not like what was on offer on the day of inspection and had asked for an alternative, and had been told that it might be difficult. This was provided once the inspector had discussed alternatives with the assistant cook. Popham House D53-D02 S16052 Popham House V230433 120705 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 and 18. A complaints procedure is made available to service users to allow them to raise any concerns. Service users rights to vote in local elections were encouraged. Appropriate steps were being taken to reduce the risk of harm or abuse to service users. EVIDENCE: The complaints procedure is found within the statement of purpose, which is given to each service user. It is displayed on the home notice board and is named ‘Seeking Your Views’. All service users spoken to said they had no complaints and would know whom to talk to if they did. A complaints record is kept and the home had not received any complaints since the last inspection. One service user told the inspector that any concerns raised with the manager had been dealt with very well. All staff before commencing employment at the home had a POVAfirst check as part of an enhanced CRB disclosure for the protection of vulnerable service users at the home. Four recruitment files sampled evidenced this. All service users are registered to vote either by post or by being taken to the local polling station. Photographs seen on the notice board in the entrance hall, evidenced visits by local politicians. Popham House D53-D02 S16052 Popham House V230433 120705 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. Service users live in a homely, clean environment where they can enjoy the privacy of their own bedrooms or socialise in a variety of communal areas. EVIDENCE: All communal areas and at least eighteen bedrooms were seen at this inspection. The service users are accommodated in single bedrooms, which are fitted with a wash hand basin, some have en-suite toilets. Bedrooms are situated on the first and second floor and are accessed by a passenger lift and stairs. Service users are encouraged to personalise their rooms and staff ensure that the privacy and dignity of service users is respected. This was evident at inspection. All service users had accessible locks on their bedroom doors. Service users spoken with informed the inspectors that they were happy with their rooms. Popham House D53-D02 S16052 Popham House V230433 120705 Stage 4.doc Version 1.30 Page 15 Equipment such as walking aids, grab rails and wheelchairs were available to assist with maintaining independence. During the inspection, service users were observed utilising the communal areas, of a quiet lounge, larger TV lounge and dining area. All windows at the home had been replaced with attractive double glazed units. The home had adequate specialist bathing and toilet facilities for service users. The home appeared well maintained. Maintenance records were kept, which included routine maintenance. Environmental Health last visited the home in September 2004. The Fire Officer visited last in May 2004. The cleanliness of the home was very good at this inspection. There were no offensive malodours. Hand washing facilities were available for staff throughout and included the provision of alcohol gel. Resources were available to aid in infection control such as aprons and gloves. The laundry area was not seen at this inspection. The main laundry is shared at the home next door The Court. Popham House D53-D02 S16052 Popham House V230433 120705 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30. The home’s recruitment procedures for staff were robust and protected service users from the risk of abuse. The numbers and skill mix of staff were appropriate to meet the needs of current service users. Staff morale was good. EVIDENCE: As part of the inspection process four staff recruitment files were sampled and examined. All contained documentation required by legislation for the protection of vulnerable adults. The home records a duty rota of staff on duty at all times on a weekly basis. Copies were sent to the inspector as part of the inspection process. These indicated that staffing normally exceeds minimum staffing levels set by the old health authority. Staff and service users spoken to indicated that the staffing levels were always adequate. Evidence was seen that agency staff are used to cover any shortfalls. Measuring service user dependency levels has indicated staffing requirements at the home. During the inspection the inspector was told that when nursing beds rise to 32 from 30, care hours will be increased by 12 hours per week. A second Registered Nurse is on duty at lease 3 days per week. Staffing will continue to be monitored by the CSCI as nursing beds increase. Popham House D53-D02 S16052 Popham House V230433 120705 Stage 4.doc Version 1.30 Page 17 Dependency levels of service users are regularly reviewed. Evidence of this was seen in the care plans examined. Thirty-one service users were residing at the time of this inspection and staffing levels were above minimum on the day of inspection. There is an on call system at the home to include the manager and her deputy. Staff training at the home is on a rolling programme and includes, for example, mental health awareness training, abuse awareness, risk assessing, NVQ 2 and 3 in care and health and safety training which includes: • • • • • Manual handling Infection control First Aid Basis and Advanced Food Hygiene And Fire Awareness training. 49 of staff had gained an NVQ in care. Staff spoken to confirmed the training they had received. The home is on track to have at least 50 of the staff trained to NVQ level 2 in care or above by end of 2005. Staff appeared relaxed and happy on the day of inspection and told the inspector that they enjoyed working at the home. Service users complimented the staff group. Popham House D53-D02 S16052 Popham House V230433 120705 Stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 37 and 38. The registered manager and her deputy effectively manage the home. The home is committed to staff training. The systems in place for ensuring the health and safety of service users and staff were good. EVIDENCE: Hazel Jones continues to effectively manage the home. Winnie Abrahams had been promoted to deputy manager since the last inspection. Service users and staff spoke highly of the managers. It was evident having spoken to staff and service users on the day of inspection, that the manager and deputy communicate a clear sense of direction, and lead the staff in a way that they understand. Popham House D53-D02 S16052 Popham House V230433 120705 Stage 4.doc Version 1.30 Page 19 The area manager had recorded monthly Regulation 26 visits. Action had been taken within agreed timescales to implement the requirement identified in the last CSCI inspection report. Evidence of residents/relatives meetings were seen. Minutes were recorded. Service users spoken to confirmed attending meetings and indicated that actions were taken on issues raised. Service users and visitors were made aware of the inspection by a poster being displayed on the main notice board. Service user surveys had been distributed in May 2005 and returned for auditing. These enable the manager to act on any concerns raised. Many were very complimentary of the homes provision of care. The CSCI sent comment cards to all service users and had not received any in return at the time of this inspection. Staff had formal supervision and records were seen at inspection in the staff files sampled. The records seen at inspection were up to date and in line with current legislation. The service records were as follows: • • • • • • • The hoists had been serviced last on 16/06/05. The passenger lift was last serviced on 16/06/05. PAT records were current. The fire records were examined, the home conducts weekly fire checks the last recorded check was on 08/07/05 The emergency lighting and fire equipment was last serviced on the 25/05/05. Emergency lighting was tested on a monthly basis. The Electrical Hard Wiring was checked 01/03/05 Gas servicing was last done on 26/05/05 Records indicated that staff attended regular fire training. There were a total of 10 accidents recorded since the last inspection. COSHH records were maintained. There have been nine deaths at the home in the past 12 months. The home has informed the CSCI of any serious incidents. The main kitchen, which is based at The Court, was not assessed at this inspection. Popham House D53-D02 S16052 Popham House V230433 120705 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 x x 3 3 3 3 Popham House D53-D02 S16052 Popham House V230433 120705 Stage 4.doc Version 1.30 Page 21 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(2) Requirement Evidence must be seen in the individual care plans that service users or their representaives/relatives have agreed and had input into developing their care plan. Timescale for action 30 November 2005. 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 Good Practice Recommendations There were no recommendations made at this inspection. Popham House D53-D02 S16052 Popham House V230433 120705 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Popham House D53-D02 S16052 Popham House V230433 120705 Stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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