Inspection on 11/01/08 for Poplars

This inspection was carried out on 11th January 2008.

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

Poplars 01/12/08

Poplars 09/02/07

Poplars 29/11/05

Poplars 22/07/05

Poplars 18/06/04

Poplars 23/09/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Poplars Poplars 15 Ickenham Road Ruislip Middlesex HA4 7BZ Lead Inspector Sue Woolnough Singh Key Unannounced Inspection 10:30 11 and 21st January 2008 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 Poplars DS0000027119.V356244.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. Poplars DS0000027119.V356244.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Poplars Address Poplars 15 Ickenham Road Ruislip Middlesex HA4 7BZ 01895 635 284 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) Appcourt Limited Trading as: Ms Debra Fairholme Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Poplars DS0000027119.V356244.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home shall not accommodate Severely Mentally Infirm residents Date of last inspection 9th February 2007 Brief Description of the Service: The Poplars is a care home registered for 27 older people. The home is on three floors; there is a lift in place. The home is situated in the centre of Ruislip, close to shops and public transport. There is a large rear garden and a large parking area to the front of the home. All bedrooms are single and have en suite facilities. The staff room and laundry are to the rear of the property. The number of service users accommodated has not changed. The weekly fees for the home range from £420 - £585 per week. There are additional charges for hairdressing, chiropody, toiletries and newspapers. Poplars DS0000027119.V356244.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality Rating for this service is 2 star. This means that people who use this service experience good quality outcomes. This was an unannounced inspection of Poplars Care Home. The Inspection took place on the 11th January 2008 and the 21st January 2008. All of the Key National Minimum Standards for Older People were assessed. The Inspector spoke with six people who use the service. Two people individually and four people as a group in the conservatory. The Inspector spoke with a family member of one person who lived at the home. A tour of the building took place and care records, staff records and health and safety records were examined. The Inspector carried out the inspection with the assistance of the Registered Manager. What the service does well: What has improved since the last inspection? The home had worked towards meeting the requirements from the last inspection. Care plans are up to dated and have been printed for ease of reading and amendment. A large Fat Screen Television has been purchased for the lounge. Odour control has been improved in the area identified at the last inspection with good cleaning systems in place for carpets. Poplars DS0000027119.V356244.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Poplars DS0000027119.V356244.R01.S.doc Version 5.2 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 Poplars DS0000027119.V356244.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People only move into the home once their needs have been assessed. EVIDENCE: The care files of four people who had recently moved in to the Poplars Care Home were examined. These contained assessments; people placed by a Local Authority had been assessed for their level of need. People entering the Poplars on a self-funding basis receive an assessment carried out by the home. The home will request a FACE assessment for people who are being discharged from hospital directly to the home. Poplars care home does not offer a programme of intermediate care for service users. Poplars DS0000027119.V356244.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is 7, 8, 9 and 10. This judgement has been made using available evidence including a visit to this service. The care plan provides information on the personal care and health of people who use the service. Procedures and training are in place for the safe handling of medication. The six people spoken with made positive comments about the staff team and the attitude of staff towards the care they received. EVIDENCE: The care plans of four people who use the service were examined. These contained all the necessary information such as a service user plan and daily records. The care plan covered guidance for staff on people’s daily care such as personal care, physical well being, mobility, dexterity, mental state and cognition and social and religious needs. The care plan format has remained Poplars DS0000027119.V356244.R01.S.doc Version 5.2 Page 10 the same since the last inspection, although care plans are now typed and printed. The Registered Manager indicated this made amendments and updates easier. The four care plans seen by the Inspector covered the individual care needs of the people using the service and had all been reviewed recently. The care plans are reviewed regularly with dates that people have been attended to by health care professionals. Generally people register with a local General Practitioner; some people who do not originate from the locality are able to stay with their own General Practitioner although this is not often the case and they are transferred by their GP Practice. People who have additional health care needs are referred to the District Nurse. The District Nurse was treating one person whose care records were seen and another had appointments at a day hospital so that his/her medical condition could be kept under review. A Dentist and District Nurse visited the home. Two senior staff had recently received training in toenail cutting. Senior staff are responsible for the administration of medication and receive training for this. Medication is stored and administered from Blister Packs. The Medication room, cabinet and medication administration records were found to be in order. The Inspector spoke with a senior member of staff who explained the system in place for the collection and return of medication; a local Pharmacist manages this. All of the bedrooms at Poplars are singe. A telephone is available in the lounge and the corridor. There are telephone connections if required in individual bedrooms. People spoken with who use the service generally commented that there is a permanent staff team and that staff are ‘kind’ and ‘cheerful.’ Poplars DS0000027119.V356244.R01.S.doc Version 5.2 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. 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. Activities are available in the home. People are consulted in residents meetings about activities. People are able to receive visitors in private and are able to exercise some choice with regard to their daily routines. People are provided with a balanced diet, which they are satisfied with. EVIDENCE: The Inspector spoke with six people who use the service about activities and leisure pursuits offered in the home. People named some of the activities that are available in the home; these include quizzes, music and bingo. One person said that she likes to do needlework in her bedroom and go out shopping. People mentioned that there had been outings in the summer and nice Christmas events. The Registered Manager said that activities are offered each day but sometimes the response is poor. Activities are a regular agenda item Poplars DS0000027119.V356244.R01.S.doc Version 5.2 Page 12 at residents meetings. At one meeting people said they would just prefer to watch television. Christmas parties and events had been successful and enjoyable; there was a good family attendance at these. A record of daily activities is made. A Church Service is held in the home once a month. Information of the Dataset stated that twenty-four people are of a Christian denomination. People are able to receive visitors in their bedrooms. The rear extension lounge is also a quieter place to receive visitors. A coffee morning is organised every Friday morning for the benefit of friends and families, this is not always well attended. People are able to maintain links with the community; this is usually if they go out shopping or for outings. People spoken with made general comments about life in the home, routines and choices. These comments were that people were satisfied with the home and liked the staff. One person said that he/she was not really interested in activities and preferred to spend most of the time in the bedroom and have meals there also. Family manage the financial affairs of people who live at the home in the majority of cases. A small number of people manage the money they require for daily living expenses. This is done with minimum assistance of staff. People spoken with confirmed that there is a choice at meals and one person said that the Chef is willing to prepare something different if requested. The menu for a three-week period was seen; mainly traditional British dishes are cooked with the occasional curry and pasta dish. Soup, sandwiches and light snacks are available at teatime. Residents meetings had taken place on a regular basis where the menu is a regular agenda item. Poplars DS0000027119.V356244.R01.S.doc Version 5.2 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. 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. A complaints procedure is in place for service users and relatives/visitors. Training is in place for staff on safeguarding adults. EVIDENCE: A complaints procedure is available for the use of people who use the service and relatives. The complaints procedure and information on an Age Concern Advocacy Service is accessible. These two documents are in the reception area. The Inspector looked at the complaints record there had been no complaints since the last inspection. One person who uses the service said he/she knew of the complaints procedure when asked, another person said he/she would talk with the Manager if there was a complaint. A Whistle Blowing procedure is available for staff this was reviewed in 2007. Information provided by the Registered Manager stated that seven staff had received training in the Protection of vulnerable adults in 2007 and that Adult Protection is also covered as part of the video training offered in-house. It was not clear from the records that all staff had received this training. Poplars DS0000027119.V356244.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23, 24 and 26. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is suited to its stated purpose. The home is clean, spacious and comfortable. EVIDENCE: The Poplars provides a well-maintained environment for people who use the service. Accommodation comprises of a spacious lounge and separate dining room; part of the lounge is an extension to the rear overlooking the garden. All of the bedrooms are single and have on-suite facilties. There are four bathrooms. There is parking to the front of the home; at the rear are gardens and a laundry. Poplars DS0000027119.V356244.R01.S.doc Version 5.2 Page 15 A number of improvements have been made since the last inspection. These include new carpets to some bedrooms, a large flat screen television which could be seen in the lounge and a new water urn for the kitchen. During the tour of the building the Inspector was bale to see some bedrooms, which had been personalised to suit peoples tastes. In addition to the above improvements anti-bacterial hand scrub has been made available at certain locations such as entry to the kitchen and outside of toilets. There is a policy for staff on Infection Control. The home looked clean and tidy in all the areas seen by the Inspector. Poplars DS0000027119.V356244.R01.S.doc Version 5.2 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. 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 staff on duty meet the daily needs of people who use the service. Staff are offered the opportunity to undertake NVQ training in care to improve their skills in residential care work. Mechanisms are in place to ensure that prospective employees are suitably checked when recruited. Mandatory and skills training is available to enable staff to work competently, all staff must receive this training. EVIDENCE: There has been no change to the number of staff on duty since the last inspection. There are four carers on in the morning with a senior carer as supervisor and three care staff on the afternoon/evening shift with a senior carer. At night two waking night staff are on duty. Permanent staff cover vacant shifts; the Registered Manager does not use agency staff in the home. Nineteen staff are in the home, thirteen full time carers, three part time carers and three support staff. Poplars DS0000027119.V356244.R01.S.doc Version 5.2 Page 17 At the time of the inspection seven care staff had obtained NVQ Level 2 and six care staff were working towards NVQ Level 2. Unfortunately, some staff that had achieved this had left employment at the Poplars. The staff personnel/recruitment records of two members of staff relatively new to the Poplars were examined. These contained application forms, identity verification and references. A Criminal Records Bureau Check and POVA first check had been carried out for both members of staff. Information on training was provided by the Registered Manager this was provided in the Annual Quality Assurance Assessment, Business Plan and in the form of a spreadsheet. Mandatory training is covered as part of the in–house induction and covers moving and handing, fire evacuation, food hygiene, infection control, heath and safety and protection of vulnerable adults. Staff had undertaken Food Hygiene training in 2007 and Protection of Vulnerable Adults. Training in medication, food hygiene and basic first aid are panned for 2008. The information presented did not make it clear that all staff had received mandatory training or protection of vulnerable adults training. The Common Standards of Induction and Foundation Training (skills for care) are not provided as part of the training package. Poplars DS0000027119.V356244.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager has the skills and competence to administer the home in a competent manner. People are given the opportunity to put forward their views on the home. The home is not responsible for the management of people’s financial affaires. Practices are in place for the health and safety of people who use the service. Poplars DS0000027119.V356244.R01.S.doc Version 5.2 Page 19 EVIDENCE: The Registered Manager has worked at the home for a number of years and has the competence and experience to fulfil her role. The Registered Manager has just completed her NVQ in Management of Care. The Registered Manager was able to identify areas for improvement in the home; these were contained in a brief business plan. Residents meetings take place whereby people are asked for their views. The last two residents meetings had taken place in August and September 2007. Activities and menu’s were the main topic discussed. Quality Assurance Questionnaires had been distributed to people who use the service, staff, family and professionals. The results need to be compiled and incorporated into the annual development plan. The Registered Manager confirmed that the home does not administer the financial affairs of people who use the service. A small number of people are supported with small allowances for daily requisites. The Inspector toured the premises; there were no health and safety concerns noted on this occasion. A monthly health and safety audit takes place records of these were seen. A risk assessment for the kitchen and fire risk assessments were seen. A risk assessment had also been competed for the premises in general. Risk assessments seen on peoples files covered moving and handling and going out alone. A list of date’s equipment had been maintained/serviced was provided in the Annual Quality Assurance Assessment. The Inspector sampled a small number of these. The fire alarm system had been serviced in August 2007, fire blankets and extinguishers in September 2007 and electrical appliances in November 2007. The Gas boiler had been serviced and Legionella testing had been carried out. The Registered Manager said that health and safety are included in the staff induction process and gave a good example of how she encourages staff to assess risk in their daily work practice. Poplars DS0000027119.V356244.R01.S.doc Version 5.2 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 X X 3 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 3 18 x 3 3 X X 3 3 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 X 3 X X 3 Poplars DS0000027119.V356244.R01.S.doc Version 5.2 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 OP30 Regulation 18 (1) (a) Requirement Timescale for action 01/04/08 2. OP30 18 (1) (a) 3. OP33 24 The training and development plan must include all staff on mandatory and protection of vulnerable adults training. The Registered Provider and 01/04/08 Registered Manager must ensure that in addition to in-house induction training, the core common induction standards are covered. The Registered Provider and the 01/05/08 Registered Manager must include the outcome of resident surveys in the annual development plan. 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 Poplars DS0000027119.V356244.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Poplars DS0000027119.V356244.R01.S.doc Version 5.2 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. 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