Inspection on 17/04/07 for Popham Court

This inspection was carried out on 17th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 06/01/06

Popham Court 12/07/05

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 Court Courtland Road Wellington Somerset TA21 8NE Lead Inspector Kathy McCluskey Key Unannounced Inspection 10:00 17 & 18th April 2007 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 Popham Court DS0000016052.V334707.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. Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Popham Court Address Courtland Road Wellington Somerset TA21 8NE 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) 01823 662513 01823 669216 hazel.jones@somersetcare.co.uk Somerset Care Limited Hazel Anne Jones Care Home 74 Category(ies) of Old age, not falling within any other category registration, with number (74) of places Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 74 persons aged 65 years and over (OP), and within the registered numbers 32 persons over the age of 60 years requiring nursing care can be accommodate. Date of last inspection Brief Description of the Service: Sine the last inspection the CSCI have approved an application for Popham House and The Court to be registered as one service. The home is now known as Popham Court and is registered with the Commission to provide General Nursing care to 32 service users over the age of 60 years and personal care to 42 service users over the age of 65 years. Somerset Care Ltd owns the home and the Registered Manager is Hazel Jones. Social services currently have a block contract for 19 nursing beds and 18 personal care beds. Four nursing beds 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 bed is a respite nursing bed funded by social services. The home is situated in a convenient location just a short distance from Wellington town centre where there are a range of shops, banks and other facilities. Adjacent to the home is a Community Park. Popham Court benefits from award winning, large and beautifully maintained gardens, which are easily accessible to wheelchair users. A range of garden furniture is available to service users. All areas of the home have been suitably adapted for wheelchair users/mobility difficulties. The home’s current fee range is £420-£450 per week for personal care and £600-£630 per week for nursing care. Additional charges include: chiropody, hairdressing, magazines/newspapers, personal toiletries/items and a small contribution to outings. Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are; - excellent, good, adequate and poor. This is the home’s first inspection since the Commission approved an application for Popham House and The Court to be registered as one service. Given the size and layout of the home, this key unannounced inspection was conducted over 2 days (11.5hrs) by CSCI regulation inspectors Kathy McCluskey and Jane Poole. At the time of this inspection 29 service users were receiving nursing care and 32 personal care. Deputy managers Winnie Abrahams and Audrey Gilgrist were available throughout the inspection. The registered manager Hazel Jones was available on the second day of the inspection. As part of this key inspection, the Commission sent comment cards to G.P’s, healthcare professionals and a selection of service users, staff and relatives. 2 completed comment cards have been received from G.P’s, 2 from staff, 3 from service users and 5 from relatives. Comments have been incorporated throughout the report. The inspectors would like to thank service users, staff and the management team for their time and co-operation throughout the inspection process. The inspectors were made to feel very welcome. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: Popham Court consists of two separate buildings, Popham House which provides nursing care with some personal care beds and The Court, which provides personal care only. The home also offers day care and respite care. Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 6 Service users have access to large and beautifully maintained gardens. The home is ideally located next to Wellington park and is only a short walk into the town centre and bus routes. The home is managed by a competent and experienced registered manager who is supported by two deputy managers. Service users benefit from a staff team who have been appropriately trained. Somerset Care and the home promote and support training and development programmes for all staff to ensure that staff have the appropriate skills to meet the needs of service users. Staff spoken with during the inspection were very positive about the training and support they received. The home ensures that no service user moves to the home unless they have been appropriately assessed. Prospective service users and/or their representatives are invited to visit the home. Detailed information about the home and services offered is made available. This is to ensure that service users can make an informed choice about living at Popham Court. Five relatives completed comment cards for the Commission and all confirmed that they had received enough information about the home prior to their relative moving in. This was also confirmed by a relative spoken with during the inspection. Service users who were able to express a view, informed the inspectors that they had been able to make an informed choice about moving to the home and all stated they were happy with the care they received. This was also confirmed in the three comment cards received from service users. The home’s care planning procedures promote a person centred approach to care and ensure that assessed needs and preferences are met. Service users have very good access to appropriate healthcare professionals. Two comment cards were received from G.P’s and responses were positive. Comments made were; ‘no concerns’, ‘Excellent care and nursing staff are available when I visit’. The home follows the correct procedures for the management and administration of service users medication. Staff at the home ensure that service users are treated with respect and that their privacy is respected. ‘End of life’ care and support is very good. Service users have access to a range of activities though service users receiving nursing care would benefit from more activity hours. The home promotes links with the local community and ensures that visitors are made to feel welcome. Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 7 Service users benefit from a wholesome and varied menu where choices are offered. All meals are freshly prepared at the home. The home’s arrangements for the presentation of soft diets needs improving. The home follows the correct procedures to reduce the risk of harm or abuse to service users and to ensure their health and safety. In response to the question in the commission’s comment card, ‘What do you feel the care home does well’, relatives made the following comments; ‘The home has a feel good factor whenever we visit’, ‘staff are on hand and appear happy’, ‘The home is always clean and friendly’, ‘They treat my relative as an individual and with respect’, ‘Staff work hard through difficult times and seem professional’. What has improved since the last inspection? What they could do better: No requirements were raised at this inspection. Some good practise recommendations have been raised and relate to the following; The home’s care planning systems were good and detailed daily entries are maintained as to the well-being of service users. Records did not always demonstrate that care plans were being formally reviewed at least monthly. The inspectors spent time observing life in the home and talking to service users. As a result of this it has been recommended that the registered providers give serious consideration to increasing activity hours for those service users receiving nursing care. Given the high dependency levels of service users receiving nursing care, it has been recommended that the care staffing levels at night for Popham House (Nursing) are reviewed and increased. It should be pointed out that no serious concerns were raised regarding the ability to meet individual’s assessed needs. The home follows the correct procedures for the reporting and recording of all accidents though it has been recommended that the procedures for analysing Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 8 accidents is reviewed so that it includes systems for identifying any traits and for recording any action taken to prevent reoccurrence. 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. Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Standard 6 is not applicable. Quality in this outcome area is Excellent This judgement has been made using available evidence including a visit to this service. Prospective service users and their representatives are provided with the information they need to enable them to make an informed choice about moving to the home. The home takes appropriate steps to ensure that it can fully meet the assessed needs and aspirations of service users. Service users benefit from a very well trained staff team. EVIDENCE: The home provides detailed information for service users, prospective service users and their representatives. Information about the home can be found in the Statement of Purpose and Service user Guide. Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 11 Five relatives completed comment cards for the Commission and all confirmed that they had received enough information about the home prior to their relative moving in. This was also confirmed by a relative spoken with during the inspection. Service users who were able to express a view, informed the inspectors that they had been able to make an informed choice about moving to the home and all stated they were happy with the care they received. This was also confirmed in the three comment cards received from service users. All service users are issued with a contract which clearly identifies the terms and conditions of residence. Social services contracts are in place where applicable. The home takes appropriate steps to ensure that the assessed needs and aspirations of prospective service users can be met. Prospective service users are fully assessed by a member of the management team prior to a placement being offered. Assessments from other healthcare professionals are also obtained where available. Prospective service users and/or their representatives are encouraged to visit the home prior to making a decision. Evidence of pre-admission assessments were seen in the six care plans examined. The home also offers day care, interim nursing beds and a ‘step up- step down bed’ for personal care. The purpose of this bed is to reduce unnecessary admissions or prolonged stays in hospital or residential care (step up) and to facilitate early discharge from hospital for people who are clinically ready to transfer, but are needing a further period of rehabilitation (step down). People using this bed will have received a multidisciplinary assessment which would clearly identify their individual care needs. These assessed needs are met by the home to ensure that the agreed outcomes are achieved. The usual placement is six weeks. Somerset Care promote and support training and development programmes for all staff to ensure that staff have the appropriate skills to meet the needs of service users. Staff spoken with during the inspection were very positive about the training and support they received. Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is Excellent This judgement has been made using available evidence including a visit to this service. The home’s care planning procedures promote a person centred approach to care and ensure that assessed needs and preferences are met. Service users have very good access to appropriate healthcare professionals. The home follows the correct procedures for the management and administration of service users medication. Staff at the home ensure that service users are treated with respect and that their privacy is respected. ‘End of life’ care and support is very good. EVIDENCE: Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 13 The inspectors examined six service user care plans in depth at this inspection. The home is in the process of completing a computerised care planning system, though is retaining paper copies to enable easier access to service users and/or their representatives. The inspectors recommended that the home ensures that only current care plans in use are maintained in the paper copy file. The inspectors acknowledged that the home was still in the process of updating these systems and were informed that this would be addressed. Five of the care plans seen promoted a person centred approach to care. Only one had not been fully personalised. Care needs were clearly identified and interventions for staff were very detailed and included the preferences of service users. Appropriate assessments were in place which included; reducing the risk of pressure sores, moving and handling needs, nutrition and individual risk assessments. Staff monitor and record service user’s weights on a monthly basis and the inspectors were able to see evidence that appropriate action had been taken where concerns had been identified. Whilst care plans contained appropriate information including daily detailed entries as to the well-being of service users, it was not clear that all care plans seen had been reviewed at least monthly. In some care plans, including those on the computer there appeared to be gaps in the review process. This was discussed with the management team during feedback and it has been recommended that care plans are reviewed at least monthly. The management team also agreed to ensure that more detailed information is provided in one care plan for a service user with diabetes. This related to acceptable ranges for blood glucose levels. The majority of care plans contained information regarding the social history of service users. Information had been provided by the service user or, as appropriate their representative. The management team informed the inspectors that they were in the process of obtaining this information for all service users. This is felt to be positive. The inspectors were able to see evidence that service users or their representatives had been involved in the care planning process. The home confirmed excellent support and input from healthcare professionals and G.P’s. Detailed records are maintained relating to individual service user’s contact with all other professionals. Two G.P’s completed comment cards for the Commission and responses were positive; ‘No concerns’, ‘excellent care’, ‘nursing staff always available during visits’. Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 14 Service users spoken with during this inspection were positive about the care they received and all commented on the kindness of the staff. All service users spoken with informed the inspectors that staff treated them with respect and that their privacy was respected. During the inspection, staff were heard communicating with service users in a kind and professional manner. The atmosphere at the home was relaxed and ‘unhurried’. ‘Do not disturb’ signs are available for service users on their bedroom doors. The inspectors examined the home’s procedures for the management and administration of service users medication in both the nursing and personal care units. The home uses the monitored dosage system (MDS) with preprinted medication administration records (MAR). All medicines were found to be securely stored and MAR charts appropriately completed. No excess stocks were noted. Correct procedures are followed for the management and administration of controlled drugs and the home has introduced additional robust procedures relating to this. Medicines received into the home are appropriately recorded and correct procedures are followed for the disposal of medicines. Registered nurses are responsible for the administration of medicines for service users receiving nursing care. Medicines for service users receiving personal care are administered by appropriately trained senior care staff. The home’s last community pharmacy advice visit was conducted on 20/06/06. Providing assessed needs can be met, service users can spend their final days in the comfort of their own bedrooms. The home ensure that the ‘end of life’ preferences of individual’s are met and that the service user and their family receive appropriate support. The registered manager and deputy confirmed that, as appropriate, additional staff would be put in place to ensure that service users received the care and support they needed. The deputy manager for the personal care unit (The Court), confirmed that they received excellent support and input from the palliative care team. Care plans examined contained information as to the preferences of service users following death. Staff confirmed that they had received appropriate training in end of life care/palliative care. Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 15 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. Service users have access to a range of activities though service users receiving nursing care would benefit from more activity hours. The home promotes links with the local community and ensures that visitors are made to feel welcome. Service users benefit from a wholesome and varied menu where choices are offered. The home’s arrangements for the presentation of soft diets needs improving. EVIDENCE: The inspectors spent time talking with service users in both the nursing (Popham) and personal care (The Court) units, about their life at the home and about activities available to them. Records relating to activities were also examined. It should be pointed out that the experiences of service users living in the Court differed to those living in Popham due to the different needs and Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 16 abilities of the service user group. The majority living at Popham require high dependency nursing care and therefore their abilities are more limited than those living at the Court. The inspectors noted that service users living at the Court benefit from an activities co-ordinator five days a week whilst Popham only have an activities co-ordinator for three days a week. It has been recommended that the registered providers (Somerset Care) review this arrangement and give consideration to additional activity hours at Popham. The inspectors have made this recommendation due to the fact that these service users have complex nursing needs and the majority are dependant on staff to meet all activities of daily living. Records relating to activities for Popham were quite limited and the inspectors acknowledged that it was difficult for the activities co-ordinator given the part time hours and needs/abilities of the service user group. On the first day of the inspection there was no activity cover at Popham. At the Court, the activities co-ordinator had arranged a ‘parachute’ exercise session and reminiscence for service users and later in the afternoon, the activities organiser was observed with service users in the garden. Comments received from service users were as follows; ‘I don’t go out much but on Fridays the ‘pat dogs’ come’, ‘don’t have enough to do’, (Popham). ‘They take us out’, ‘always something going on if you want to join in’ (the Court) A ‘trolley shop’ is available to all service users every Friday. The home has a wheelchair accessible mini bus. The home ensures that service users are supported to make choices over their lives. As previously mentioned in this report, the preferences of service users are clearly identified in individual care plans. The majority of service users spoken with confirmed that they were able to make choices about how and where they spent their day. As previously mentioned in this report, the majority of service users in Popham have complex nursing needs and are dependant on staff to meet all activities of daily living. Many are unable to mobilise independently and are therefore dependant on staff when making choices. The registered manager and management team confirmed that all service users are supported to make choices. Many of the service users informed the inspectors that they enjoyed visits from their friends and family. One relative spoken with during the inspection informed the inspectors that they were always made to feel very welcome and were always offered refreshments. Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 17 The home promotes links with the local community for service users. Local churches are accessed. The home holds regular community events to raise money for service users, the most recent being an easter fun day. All meals are freshly prepared at the home. The main kitchen is located in the Court. Popham and the Court benefit from spacious dining areas with comfortable seating. Without exception, all service users spoken with during the inspection were very complementary regarding the meals offered at the home. Menus are displayed and choices are available. A selection of menus were made available to the inspectors and these appeared wholesome and varied. The main meal is enjoyed at lunch time, teatime is a lighter option with a choice of hot or cold meals. Supper is also offered. During the week, service users can choose a cooked breakfast if they wish. Lunch was observed being served on both days of the inspection at Popham House. The atmosphere was relaxed and staff were observed assisting service users in a dignified and unhurried manner. Vegetables and potatoes were offered from serving dishes. Condiments were available. The meal looked plentiful and appetising. The inspectors did raise concerns with the deputy manager on the first day of the inspection regarding the manner in which soft diets had been served. It appeared that the meal had been mixed together in a pudding type bowl. This has resulted in a substance that looked unappetising. The deputy manager took immediate action to rectify this and informed the inspectors that each item should have been presented separately. She did explain that given that the meal had to be very soft, it was difficult to serve on a plate. The inspectors acknowledged this and recommended that the home looks into purchasing suitable adapted plates. Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 18 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 has satisfactory complaints procedures in place. The home takes appropriate steps to reduce the risk of abuse to service users. EVIDENCE: The home’s complaints procedure, ‘Seeking your views’ is displayed in the home and is also available in the Statement of Purpose. Service users who were able to express a view informed the inspector that they would raise concerns if they had any. One relative spoken with stated that the management team and staff were very approachable and that they felt confident in raising concerns. Three service users completed comment cards for the Commission and all stated that they knew who to speak with if they were not happy. This was also the case in the five comment cards received from relatives. Two comment cards were received from G.P’s and both stated that they had not received any complaints about the home. Since the last inspection the home has received one complaint which was fully investigated by the registered manager. The inspectors were able to see Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 19 evidence that the complainants were very satisfied with the outcome and of the pro-active approach of the registered manager. No complaints have been raised directly with the Commission. The home takes appropriate steps to reduce the risk of harm or abuse to service users. Correct procedures are followed for staff recruitment which includes an enhanced criminal records check (CRB) and protection of vulnerable adults check (POVA). The home has procedures available to staff relating to adult protection. Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 20 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, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Popham Court provides a comfortable environment with beautiful gardens and service users are able to personalise their bedrooms. Service users have access to a range of specialised equipment and other aids to maximise their independence. Storage arrangements are limited. The standard of cleanliness is very good and the home takes appropriate steps to reduce the risk of the spread of infection. EVIDENCE: Popham Court consists of two separate buildings, Popham House (Nursing) and the Court (personal care only). Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 21 Popham House has 36 bedrooms, large dining area, large lounge which can be divided into two smaller lounges and a conservatory. On the first day of the inspection, the lounge was divided into two, space appeared limited and a number of service users required specialised nursing chairs. On the second day the lounge had been opened up to provide one large area. Although this appeared more spacious, this arrangement could have an impact on the choice/preference of service users if they did not want to watch or listen to the television. The conservatory was not seen to be fully utilised as part of it was being used to store hoists and wheelchairs. There are two communal bathrooms and two shower rooms. One of the shower rooms has recently been refurbished and now provides a spacious ‘wet room’. Detailed information about the home’s environment and sizes of rooms can be found in their statement of purpose. During this inspection the inspectors were able to view some bedrooms and all communal areas. Bedrooms were nicely furnished and it was apparent that service users had been encouraged to personalise their bedrooms. Adjustable nursing beds or profiling beds were in place. Some bedrooms appear quite small though staff spoken with did not express any concerns about being able to meet nursing needs and no concerns were raised by service users. Service users informed the inspectors that they liked their bedrooms. The Court has 36 bedrooms, large dining room, two large lounges one of which service users may smoke and a smaller lounge. Assisted bathrooms and toilets are appropriately sited throughout the home. A selection of bedrooms and all communal areas were seen. Bedrooms were comfortably furnished and had been personalised by service users. A call bell system is fitted throughout the home. Shaft lifts give access to the first floors. Grab rails are appropriately sited. The home has a good supply of hoists and moving & handling equipment. Adjustable and profiling beds are in place for those service users receiving nursing care. Storage at the home is limited so equipment such as hoists and wheelchairs have to be stored in communal areas or bathrooms. Equipment appeared to have been stored so that it did not pose a health & safety risk to service users but this arrangement did make parts of the home feel ‘cluttered’ and did take some communal space from service users. The home takes appropriate steps to reduce the risk of the spread of infection. Staff hand-washing facilities are appropriately sited throughout the home, protective clothing was seen to be plentiful. Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 22 The standard of cleanliness in all areas seen were noted to be high and there were no malodours. Service users living in both units benefit from large beautifully maintained gardens. Last year the home won an award for their gardens and they are looking forward to entering again this year. The inspectors were informed that one service user living at Popham House, enjoys helping in the gardens. Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 23 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. The home ensures that it is adequately staffed though night care staffing levels for service users receiving nursing care could be improved. Service users benefit from a well-trained workforce. Service users are protected by the home’s staff recruitment procedures. EVIDENCE: The inspectors were informed that the home is staffed as follows: Popham House The Court AM – 1 registered nurse (often 2 on duty) 1 supervisor 6 care staff and 1 care support 1 shift leader 2 domestics 4 care staff kitchen staff 2 domestics Kitchen & laundry staff PM – 1 registered nurse (with a second until 1600hrs) 5 care staff 1 care support until 1430hrs Popham Court DS0000016052.V334707.R01.S.doc 1 supervisor 3 care staff Version 5.2 Page 24 1 domestic EVE –1 registered nurse 6 care staff and 1 care support NIGHT – 1 registered nurse 2 care staff As above 1 supervisor 1 care staff The registered manager’s hours are supernumerary. A deputy manager is available in each unit and also have supernumerary hours. Administrative, maintenance and gardening staff are also employed. No concerns were raised with the inspectors regarding staffing levels during the day. Concerns were raised with the inspectors regarding the numbers of care staff on duty in the nursing wing (Popham House) during the night. Given the high dependency levels of the service users requiring nursing care and that a large number require the assistance of two staff to move/mobilise and given the layout of the home, it is strongly recommended that the registered providers review the night care staffing arrangements with a view to increasing. The registered providers and the home are pro-active in ensuring that staff have the training and skills they need to ensure that the assessed needs of service users are met. Staff spoken with were very positive about the training opportunities available to them. A detailed training programme was made available to the inspectors. There was evidence that registered nurses have completed appropriate courses to ensure their clinical knowledge and skills remain up to date. Care staff have completed courses such as person centred care, wound and skin care, diabetes, dementia and mental health, the ageing process and bereavement. All staff have completed appropriate mandatory training. Staff are supported and encouraged to do relevant NVQ training. Preinspection information supplied by the home indicated that out of the 49 care staff employed, 28 have achieved a minimum of an NVQ level 2 in care. This equates to 57 which exceeds the 50 recommended in the national minimum standards. The inspectors examined the home’s procedures relating to staff recruitment. Four recruitment files were examined. Each contained information as required in Schedule 2 of the Care Homes Regulations 2001. Enhanced CRB’s and POVA checks were available. Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 25 Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 26 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, 32, 33, 35 and 38 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. The home has a good management structure in place and the home is effectively managed. Effective quality assurance procedures are followed. The home takes appropriate steps to ensure the health and safety of service users, staff and visitors. EVIDENCE: The registered manager is Hazel Jones. Hazel is a registered nurse with many years experience. Although the registered manager’s hours are Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 27 supernumerary, she is very much a ‘hands on’ manager who will work shifts and keeps up to date with the needs and preferences of service users. Hazel has completed the registered managers award along with a number of other appropriate courses. She remains clinically updated. Staff, service users and a relative spoken with were very positive about the registered manager and her style of management. The registered manager is supported by two deputy managers, Winnie Abrahams and Audrey Gilgrist. Audrey has completed the registered managers award and Winnie is working towards this. The home has systems in place to seek the views of service users, staff, relatives/representatives. Regular meetings are held and, as part of their quality assurance programme, the home sends out quality questionnaires. A sample of the most recent questionnaires were seen and comments were positive. At the request of service users or their representatives, the home manages small amounts of money on behalf of service users. Records were examined and were found to be well maintained. Robust systems were in place for checking transactions. Monies were seen to be securely stored. The following records were examined relating to health and safety: FIRE SAFETY – The inspectors were able to see evidence that fire detection systems and fire fighting equipment had been checked and serviced in line with current guidelines and requirements. The home conducts weekly checks on the fire alarm systems and emergency lighting. Systems are serviced annually be an external contractor. All staff have received appropriate fire safety training. HOT WATER OUTLETS/HOT SERVICES Hot water outlets are fitted with thermostatic controls to ensure that they do not exceed safe upper limits as recommended by the Health and Safety Executive. The home checks all outlets monthly. Records are maintained. The inspectors tested some bath and shower hot water outlets at this inspection and they were found to be within safe limits. To reduce the risk of injury to service users, radiators have been fitted with a guard. ELECTRICAL SAFETY – The home’s maintenance person has completed training in the testing of portable appliances. Records indicated that annual testing was up to date and was due again in May. The home has an up to date electrical hardwiring certificate dated 01/03/08 and valid for 3 years. Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 28 GAS SAFETY – The home confirmed that the annual gas safety servicing had taken place this year. As the home could not locate the certificate, it was agreed that this would be forwarded to the Commission. EQUIPMENT SERVICING – The inspectors were able to see evidence that hoists, slings and shaft & stair lifts were up to date with their six monthly servicing. The certificates relating to bath hoists could not be located at the time of the inspection though were later sent to the inspectors. The nurse call system is regularly checked by the home and serviced annually by an external contractor. This last took place on 01/05/06. ACCIDENTS – Appropriate records are maintained by the home relating to all accidents and the home ensures that the Commission are informed of serious accidents as appropriate. Whilst the home has systems for regularly analysing accidents/falls, this does not clearly identify traits. This was discussed with the management team at the time and it has been recommended that these systems are reviewed so that any traits and action taken to prevent reoccurrence, are clearly identified. The home provided pre-inspection information which stated that 24 staff hold a current first aid certificate. To ensure the safety of service users, upstairs windows are restricted and wardrobes are secured to the wall. Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 x x 3 Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 30 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. 2. 3. Refer to Standard OP7 OP12 Good Practice Recommendations The registered person should ensure that service user care plans are reviewed at least monthly. The registered person should give consideration to increasing the activity hours for those service users receiving nursing care. The registered person should review night care staff levels to ensure that staffing numbers are appropriate to the dependency levels of those service users receiving nursing care. The registered person should ensure that systems for analysing accidents clearly identify any traits and any action taken to reduce the risk of reoccurrence. OP27 4. OP38 Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection South West Registration Team Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Popham Court DS0000016052.V334707.R01.S.doc Version 5.2 Page 32 - 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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