Inspection on 06/01/06 for Popham Court

This inspection was carried out on 6th January 2006.

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 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 House Courtland Road Wellington Somerset TA21 8NE Lead Inspector Caroline Baker Unannounced Inspection 09:25 6 January 2006 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 House DS0000016052.V265908.R01.S.doc Version 5.0 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 House DS0000016052.V265908.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Popham House 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 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Popham House DS0000016052.V265908.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered for seven places for personal care Date of last inspection 12th July 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. The main catering and laundry are undertaken at The Court. The home has both a small kitchen and domestic style laundry facility on site. A passenger lift is available for access to the second floor. Popham House DS0000016052.V265908.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last inspection was announced and took place on 12th July 2005. At that inspection one requirement was identified. This inspection was unannounced and took place over one day from 09:25 (3.50 hours) and was conducted by Caroline Baker. At the time of this inspection the requirement identified had been complied with. Thirty-two service users were residing at the home of which two were receiving personal care only. Staffing levels were adequate on the day of inspection. Not all of the National Minimum Standards were assessed at this inspection and this report should be read in conjunction with the last report. An assessment of the premises took place where a selection of bedrooms and communal areas were seen. At least nine service users were spoken with. Lesley Johnson registered Nurse was in charge at the home, and was available throughout the inspection. Throughout the day the inspector was able to observe interactions between staff and service users. 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 DS0000016052.V265908.R01.S.doc Version 5.0 Page 6 Service users praised the staff. Comments received included “ I am treated like a human being”, “they are all kind and caring”, “there is no-where like home but this is lovely” and “I feel safe and am well fed”. Visitors 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. 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 excellent. Staff looked and acted in a professional manner. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Popham House DS0000016052.V265908.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Popham House DS0000016052.V265908.R01.S.doc Version 5.0 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 the following standard(s): 3 and 4. NMS 6 does not apply 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. Staff individually and collectively have the skills and experience to deliver the services and the care, which the home offers to provide. EVIDENCE: Three care plans were examined as part of the case tracking process and the individual service users met at inspection. Service users confirmed that the homes manager had assessed them prior to admission, to ensure their needs could be met at the home. Pre-admission assessments were available in the care plans sampled. It was evident that the home is committed to ensuring that its staff group receive training pertaining to the needs of the service users at the home, and have the skills to care for them. Certificates of staff training were posted on the downstairs corridor walls, which included: - Popham House DS0000016052.V265908.R01.S.doc Version 5.0 Page 9 • • • • • • • • • • • • • • • Care induction Signs and symptoms Infection control Wound care Venepuncture for Registered Nurses Food Hygiene Advanced Fire Safety Non-abusive Psychological & Physical intervention Mental health awareness Company medication policy Care of medicines Appointed First Aider Health & Safety Appointed Person Palliative care And Communication Skills Registered nursing staff are on duty at the home 24 hours per day with management and on call support. The home is commended for its training provision and skill mix of staff. Popham House DS0000016052.V265908.R01.S.doc Version 5.0 Page 10 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 the following 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 review. Service users able had agreed with their written care plan. 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: As part of the case tracking process the inspector met three service users who had been admitted to the home since the last inspection, and examined their plans of care. Each care plan was written comprehensively with detailed actions to be taken by care staff reflected, to enable them to deliver the correct care. Care plans reflected current care needs. Evidence was seen that service users had input into their care plans as required at the last inspection. Popham House DS0000016052.V265908.R01.S.doc Version 5.0 Page 11 Generic, falls, pressure sore, nutritional and manual handling risk assessments were in place. 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 in hospital prior to admission. Evidence was seen that the home was effectively managing the wounds. 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 kindness and respect. Those able 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 DS0000016052.V265908.R01.S.doc Version 5.0 Page 12 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 the following 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. Activities records are held for each individual service user. These reflected the time and effort given to service users to ensure their social care needs are met. 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, and all consulted and able indicated that the Christmas programme at the Popham House DS0000016052.V265908.R01.S.doc Version 5.0 Page 13 home had been very good. On the day of inspection service users were seen watching a film. 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. Visitors spoken to were complimentary about the care provision at the home. It was evident through comments received from service users that they had a choice of daily living. Service users consulted stated that the food was always good. Everyone in the dining room at lunchtime appeared to enjoy his or her meals. The atmosphere was happy and unhurried. The kitchen at the home has been upgraded since the last inspection to include a small oven. The cook told the inspector that this had helped a great deal as now further choices could be offered e.g. omelettes, should service users not like or feel like the choices on offer. Menus were sampled and were varied and appeared nutritionally well balanced. The main kitchen is at the sister home ‘The Court’ and meals are transported across to Popham House in a hot trolley. This continues to be managed well. Popham House DS0000016052.V265908.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 16 and 18. A complaints procedure is made available to service users to allow them to raise any concerns. 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 consulted 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 in the last twelve months. The CSCI has not received any complaints against the home. 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. The recruitment files sampled evidenced this. Staff spoken to at inspection were aware of the types of abuse and steps to take should they suspect abuse. Popham House DS0000016052.V265908.R01.S.doc Version 5.0 Page 15 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 the following standard(s): 19 and 26. Service users live in a safe, homely, and clean environment. EVIDENCE: The home appeared well maintained. Maintenance records were kept, which included routine maintenance. The home complied with the local Environmental Health department and Fire department. The Fire Officer visited last in December 2005. 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. Popham House DS0000016052.V265908.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27; 29 and 30. The numbers and skill mix of staff were appropriate to meet the needs of current service users. The home’s recruitment procedures for staff were robust and protected service users from the risk of abuse. Staff morale was good. EVIDENCE: As part of the inspection process two staff recruitment files were sampled and examined. They 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 given 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 adequate. Evidence was seen that agency staff are used to cover any shortfalls. 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 adequate on the day of inspection. Popham House DS0000016052.V265908.R01.S.doc Version 5.0 Page 17 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. All staff receive mandatory training, which includes: • • • • • Manual handling Infection control First Aid Basis and Advanced Food Hygiene And Fire Awareness training. Staff spoken to confirmed receipt of mandatory training and induction. 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. The administrator informed the inspector that a member of staff had won and attended the ‘Lifetime Achievement in Care Award 2005’ in London in December 2005. Staff at the home had nominated the member of staff. A very worthwhile achievement. Popham House DS0000016052.V265908.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31; 32; 35; 36 and 38 The home is effectively managed. The home is committed to staff training and formal supervision. The systems in place for ensuring the health and safety of service users and staff were very good. EVIDENCE: Hazel Jones continues to effectively manage the home. Service users and staff spoke highly of the manager. She has completed the registered managers award since the last inspection. 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 DS0000016052.V265908.R01.S.doc Version 5.0 Page 19 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. Staff spoken to confirmed they had received formal supervision. The service records were as follows: • • • • • • • The hoists had been serviced last on 16/11/05. The passenger lift was last serviced on 29/12/05. PAT records were current. The fire records were examined, the home conducts weekly fire checks the last recorded check was on 06/01/06 The emergency lighting and fire equipment was last serviced on the 25/05/05. Emergency lighting was tested on a weekly 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 3 accidents recorded since the last inspection. There have been six deaths at the home since the last inspection. 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 and was seen as part of the last inspection at The Court. Popham House DS0000016052.V265908.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 4 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 3 X 3 Popham House DS0000016052.V265908.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Popham House DS0000016052.V265908.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street 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. 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