Inspection on 16/10/06 for Poplars

This inspection was carried out on 16th October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Poplars 25/09/07

Poplars 07/02/06

Poplars 10/02/05

Poplars 01/09/04

Poplars 13/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Poplars 63 Naze Park Road Walton On Naze Essex CO14 8LA Lead Inspector Sharon Thomas Key Unannounced Inspection 16th October 2006 09:00 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 DS0000017911.V316797.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 DS0000017911.V316797.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Poplars Address 63 Naze Park Road Walton On Naze Essex CO14 8LA 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) 01255 675557 01255 676466 Southend Care Limited Victor Zingoni Care Home 37 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (37) of places Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Persons of either sex, aged 65 years and over, who only fall within the category of old age (not to exceed 37 persons) The room registered on 30 May 2003 must not be used by a service user who uses a wheelchair Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 16 persons) The total number of service users accommodated must not exceed 37 persons The registered provider must review staffing levels (care and ancillary) in consultation with the Commission, within six months of dementia registration, to ensure that staffing levels are sufficient to meet the needs and number of service users 7th February 2006 Date of last inspection Brief Description of the Service: Poplars is a detached, two story property in Walton, Essex, in an attractive location with views over the sea. Since the last inspection, the home has had an increase in the number of registered beds from 29 to 37, incorporating 3 double rooms and 31 single rooms, 15 with ensuite toilets. Since the previous inspection the home has been registered to accommodate 16 residents with dementia. There are two large lounge/dining rooms on the ground floor, and a smaller lounge on the first floor. The home provides 24-hour personal care and support, and has a through-floor lift and other equipment (e.g. mobile hoist, hand rails, etc.) to assist residents with limited mobility. The home is registered to provide care to frail elderly people and as before residents with dementia. The registered provider is Southend Care, and the registered manager is Victor Zingoni. Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on 10 October 2006, and took 5.5 hours to complete. Twenty-one of the thirty-eight National Minimum Standards were inspected: sixteen were met and five were nearly met. For the purpose of this report the individuals living in the home and spoken with on the day stated that they would prefer to be referred to as residents. The inspection process included: discussions with three resident, the manager, and four members of staff including the cook. The tour of the premises included observation of all of the bedrooms, all of the bathrooms and toilets, the communal areas and the laundry. There was an opportunity to spend a considerable period of time observing the care being provided by the staff. The inspection covered the examination of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). The home had 8 requirements from the previous inspection report. The manager and the staff team are to be commended on the positive changes made in the home and the commitment to making the home a safer place to live in. The atmosphere in the home on this visit was calm and residents appeared happy. Action has progressed within the agreed timescales to implement requirements identified in the previous CSCI inspection report. The home was warm and comfortable with good furnishings and a good level of decoration. The residents were cared for by a team of well-trained, skilled and caring staff. What the service does well: The home provides a warm and homely atmosphere for residents. The home has created a family atmosphere despite its size. The menu in the home provides a well-balanced and varied diet for residents. The kitchen was well stocked, clean and well maintained. Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 6 Poplars has a good caring staff team, and now has a low staff turnover, staff that have left have done so for genuine reasons, such as retirement. The staff team in the home are enthusiastic, well trained and skilled. All of the residents spoken with on the day stated that the manager and staff were ‘kind and caring’ and the home was ‘very nice’. Residents reported that relatives and visitors are welcomed into the home at all times. The staff were observed to chat continually with the residents and involve them as they went about their work through out the day. The home has close links with the health care team in the area, and works with both professionals and residents to promote and maintain the residents health. The home promotes the rights of the residents and staff provide care that ensures privacy and dignity. The residents interacted comfortably with the staff. The home has a robust recruitment system that ensures that appropriate staff are employed and this in turn helps protect residents. What has improved since the last inspection? What they could do better: Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 7 The home does not have care plans that provide evidence that all appropriate information is recorded. Care plans do not contain appropriate risk assessment required to provide a detailed and accurate daily plan of care. The home does not provide appropriate social activities for the residents. Poplars does not have a dedicated activity programme that provides formal activities to residents. Medication administration records have been found to have gaps in the recording. Records confirmed that only4 of of 29 members of staff in the home had achieved the NVQ Level 2 qualification. Not all of the staff in the home have been provided with training for the Protection of Vulnerable Adults. The issues identified above are important as the lack of sufficient information in care plans could ultimately impact on the quality and standard of care that service users receive. The lack of accurate recording of medication may impact on the safety of residents. The lack of appropriate activity may result in residents not being sufficiently stimulated. The lack of PoVA training could have the potential of placing residents at risk. This report contains six requirements linked to the above issues and may be found at the end of this report. 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 DS0000017911.V316797.R01.S.doc Version 5.2 Page 8 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 DS0000017911.V316797.R01.S.doc Version 5.2 Page 9 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: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home assesses prospective residents prior to admission to ensure that individual need can be met and that appropriate admissions are made. EVIDENCE: The care plans of the four newest admissions into the home contained an appropriate Social Services assessment. The files also contained a copy of the home’s pre-admission assessment form that set out in a tick box format. The format of the document does not allow for hand written notes to be included easily. Not all of the information found in the professional assessment and the homes admission assessment was transferred over into the working care plan used by staff. This may be due to the format of the care plans and the preadmission assessment currently used by Southend Care. All resident files did Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 10 contain a care plan and further comments regarding these may be found below. The care plans did not contain evidence that the resident or relative were involved in the care plan process. Poplars does not provide intermediate care. Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 11 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: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans used in the home were insufficient and did not provide a full range of information to the staff. This lack of information has the potential of placing residents at risk. The healthcare needs of residents are addressed and well recorded. The medication systems in the home ensure the safety of the residents. The home provides a service that treated the residents with respect, staff engaged positively with residents and demonstrated a good understanding of their needs. EVIDENCE: Four care plans were examined on the day. They contained some information regarding the resident’s need, the action to address this need, and the longterm outcome/aim of the care given. The care plans did not cover all aspects of a resident’s physical, mental and social care needs. The information contained in the care plans could be described as basic and does not accurately reflect the complex needs of the residents living in the home, and this lack of Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 12 information has the potential of placing the resident at risk. The care plans of residents with dementia did not accurately reflect the specialist and complex needs of the individuals. Two of the care plans did not have a detailed risk assessment in place however and did not reflect the current situation or level of risk. Two care files contained limited information on the complex need of the resident. The issue was discussed with the manager who went on to describe the needs of the resident in detail, it was agreed that the information known about the resident must be in the care plan. Other care plans did not accurately reflect healthcare issues. The overwhelming issue found on the day was the lack of detail recorded around the action to address the resident’s need. The format of the care plan does not allow for much detail to be recorded and vital information is being lost in the process. There was little evidence that residents or relatives signed care plans or were involved in the care planning process. The daily records were up to date but contained very little evidence of the care provided in the home. Staff were observed treating residents with care and respect. Despite the lack of information in care plans the staff demonstrated that they ere aware of the needs of the residents. One resident spoken with were not aware that the home held a care plan regarding their needs. The care plans that were examined contained clear and detailed instructions for the delivery of personal care for residents. Oral and foot care were fully as was needs regarding grooming. Routine health checks offered such as optician, dentist, and chiropodist were documented. The manager confirmed that the home provided residents with access to aids and equipment to address their healthcare needs and issues. The manager confirmed that the home is well supported by the local primary healthcare team including GP’s and District and psychiatric nurses. One resident spoken with stated that they were confidant that staff would “phone for the GP if I became ill” and that “the staff are good at seeing when I am not feeling well”. The care plans confirmed that healthcare issues are picked up speedily and dealt with in an appropriate manner. The medication used in the home is securely locked and stored. The records of the administration of generic and controlled medication had gaps in recording. The record for the receipt, and disposal of medication are accurate and well maintained. All medication administration instructions recorded on the MAR reflect current GP instructions. Medication needed to be stored in a fridge were found there and medications needing to be disposed of after 28 days were dated and monitored. The staff spoken with that are responsible for giving medication confirmed that they had received appropriate training and support, and they are confident that they ensure the safety of the residents when administering medication. At the time of the visit no one in the home was able to administer his or her own medication. Through discussion with staff it was clear that they were knowledgeable regarding side effects of medication, the policies and procedures and the importance of accurate recording. The Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 13 manager reported that they had a good working relationship with the pharmacist, and is able to contact the pharmacy to seek advice if required. Overall the residents spoken with commended the staff with regard to the treatment they received in Poplars. They stated that they were treated with respect, kindness and dignity throughout the day. And this was maintained in a variety of ways, including the way staff provided personal care, toileting issues, respect for visitors, and the provision of private areas in the home that enabled residents to see visitors in private. Observation of staff during the inspection indicated that staff are friendly, considerate and respectful toward residents. Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 14 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, & 15: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does not provide an environment that meets the social and recreational preferences of the residents. The home provides the residents with flexibility and choice with regard to their daily lives. Their expectations and preferences with regard to lifestyle are met. Residents are provided with a wholesome, nutritional and appetising diet. The residents are enabled to exercise choice over what they eat. EVIDENCE: Poplars does not have a dedicated activity programme that provides formal activities to residents. There was no designated member of staff to undertake activities, and the manager stated that the general staff provide activity to residents. On the day of the inspection residents were playing a board game and completing puzzles, (although these were not appropriate to the needs of the residents with dementia). In fact there were no activities that addressed the needs of the residents with dementia. The care plans sampled did not contain appropriate detail of the social and recreation needs of the residents. The residents were observed spending time in various parts of the home, communal areas and in their bedrooms. Some residents were reading while Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 15 others were chatting with each other. The residents spoken with confirmed that the home provided a limited amount of activities in line with their preferences. Two residents reported that although they did not participate in the activities because “the things that staff do, do not interest me”. The residents spoken with confirmed that they felt that they had choices in their daily lives (e.g. where and how to spend their day, what to eat, when to go to bed, etc.). On the day of the inspection, residents spent time in various parts of the home undertaking some different activities both formal and informal. The resident spoken with commented that there “were no rules about what I do”. Staff are very clear regarding the issue of choice and reported that they had received training regarding this issue. The staff are pleasant, polite and professional in their dealings with the residents. Residents and staff spoken with confirmed that residents see relatives and professionals in private. Visitors to the home are welcomed at any time and there are no restrictions on visiting time. External entertainment is provided in the home at various times throughout the year. The staff and residents confirmed that the home encouraged residents to have contact with family, friends and the community at large. Daily routines in the home appeared flexible, with people being able to chose when to get up, where to spend their day and whether to join in with activities. The manager confirmed that the home does not act as appointee for any of the residents living there. Arrangements for residents to bring in possessions are discussed prior to admission, and records of the inventory of possessions are available. The care plans examined indicated some limited information of personal preferences in terms of food, clothes and other daily choices. Routines in the home are flexible and residents’ individual choices where possible, are addressed. The 4 weekly menus examined reflected that the home provided residents with a choice of nutritional well-cooked meals. The kitchen was clean and well maintained, and the food stocks were high and of good quality. The cook stated that a choice of meal was available and if the resident did want either an alternative was offered, the residents spoken with confirmed this. Meals are freshly prepared and cooked by the chef who has a great deal of experience. The chef was knowledgeable and skilled and has undertaken recent training in food hygiene. The meal presented on the day was appealing and the residents stated that the quality of food in the home was “very good”. Residents confirmed that the meals provided in the home were “tasty” and “well cooked” and “the cook was good at cooking”. Fresh fruit and snacks are available throughout the day, and residents confirmed that they could have a drink or snack at any time. When required, meals are liquidised and special dietary needs are catered for including low fat/high fibre and diabetic diets Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 16 . Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 16 & 18: The home has appropriate systems for responding to complaints that ensures that residents and relatives are enabled to make complaints. The home promotes the protection of service users through its policies and procedures. EVIDENCE: Poplars has developed the complaint system, and this was found to be clear and concise. The Complaint procedure document directed the individual on how and to whom, to make a complaint. It contained timescales for action, and the details of the CSCI. It was written in plain language and was user friendly. All of the residents spoken with confirmed that they were aware of the Complaint procedure, and they were able to confirm that they knew who to complain to. either a senior member of staff or the manager who they were able to name. The residents reported that they had no cause to complain. They commented that they felt confident that their concerns would be dealt with immediately. The complaint log was examined and was accurate and well maintained. One complaint had been received since the previous inspection and this was fully investigated and the detailed record of the complaint held on file. The staff spoken with confirmed that they were aware of the importance of enabling residents to make complaints. Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 18 The home’s Protection of Vulnerable Adult abuse policy and procedure examined on the day was suitable for the purpose of protecting the residents. The document had detail regarding the signs or types of abuse and contained clear and detailed information for staff. The home has a whistle blowing policy and procedure available to staff, that ensures their protection should they report bad practice. Staff were aware of these policies and reported that would feel supported to use them if the need arose. The training records reviewed on the day confirmed that all staff except six staff have received adult abuse training. The manager reported that the home had not had any reported allegations of abuse since the previous inspection. From discussion with the manager and a senior member of staff it was clear that the senior staff team and manager would benefit from in-depth external training to increase their knowledge and skill. Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 19 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 & 26: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe, well-maintained environment, which on the day of the site visit was clean and hygienic. Residents have access to safe and comfortable indoor and outdoor communal facilities. Bedrooms viewed were clean and well maintained, with suitable furniture and furnishings. EVIDENCE: The home appeared safe, and clean, however various areas in the home were in need of decoration and the residents would benefit from new carpets. However, the manager produced a memo to Southend Care requesting new carpets and re-decoration. Records of decoration and refurbishment were not inspected on this occasion: monthly reports on the home sent into the CSCI by the registered provider over the course of the last year provided evidence that regular maintenance of the home is taking place. The manager oversees the Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 20 maintenance and safety of the premises and has access to maintenance services when required. Communal lounges are large and due to this did not feel homely. The home has a secure garden area, which is well maintained and laid out. All of the bedrooms were viewed: these were similarly clean and tidy, with furniture and furnishings appropriate to the needs of residents, and personalised. One resident stated that a key factor in them choosing this home was the homeliness of the bedrooms. The home’s laundry is sited inside the main building but away from areas where food is stored or prepared. Washing machines had the facility to carry out sluice and wash cycles suitable for infection control purposes when washing soiled linen, and the laundry person was aware of which cycles to use, and of the importance of wearing protective clothing when handling laundry. Infection control policies and procedures were not reviewed on this inspection; protective clothing was seen to be available to care staff. Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 27, 28, 29, 30: Overall the home provided appropriate training to give staff the skills necessary to do their job. The majority of staff have not received NVQ 2 training. Staffing levels (number and competence) met the needs of current residents. There is a stable and loyal staff team, which ensures consisitency in the delivery of care. The home has a good recruitment procedure that ensures the safety of the residents. EVIDENCE: The staff rota examined reflected that the home was providing the agreed levels of staff. The home provided 7 carers on the morning shift, 6 on the afternoon/evening shift and 3 waking night carers. The previous inspection had highlighted that carers were working long shifts and the manager was asked to monitor the situation. From the rota examined on the day it was noted that several care staff were still working two long days per week, including two successive long days on regular occasions. Staff spoken to were very clear that this was their choice, but the manager was advised that he must monitor this Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 22 closely to ensure the health, safety and welfare of both staff and residents is not affected by staff getting over tired. On discussion with the staff it was clear that the rota was manageable and they were happy with the situation. The manager reported that the home is currently advertising for staff and that once new staff are employed the issue will be rectified. Records confirmed that 4 of 29 members of staff in the home had achieved the NVQ Level 2 qualification, and the manager is aware that this number is not satisfactory. The staff spoken with stated that they and ultimately the residents would benefit from undertaking the NVQ Level 2 training. Since the previous inspection the home has provided the staff with a full and comprehensive programme of training. The programme included: First Aid, Fire Safety, Moving & Handling, Food Hygiene, infection Control, Medication, Continence, Pressure care prevention, and Falls Prevention. However, the home has not provided staff with appropriate levels of training regarding the protection of vulnerable adults. This issue was discussed with the manager on the day and it was agreed that all staff would receive PoVA training within 6 months of the inspection. The staff spoken with reported that the training provided was relevant to their roles in the home and helped them to do their job better. The staff spoken with and staff personnel records confirmed that all prerecruitment checks are completed prior to employment. The staff files contained 2 references, a completed application forms showing employment history, names of referees, copies of Criminal reference Bureau check and PoVA First check, the manager stated that the original documents were at the home’s head office; evidence of these should be held at the home. The staff files also contained personal identification, a photograph and a contract of terms and conditions for staff. The newest recruited employee confirmed that she had received a full 5-day induction programme, and had shadowed a senior care worker until she was assessed as fit to work alone. The manager is fully aware of all the checks that are needed prior to the employment of staff; and he receives support from Southend Care in the process. Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 31, 33, 35, & 38: The home is well run by a competant manager. The home had systems in place for monitoring that the home is run in the best interests of residents. And has comprehensive systems in place to measure the quality of care provided in the home. Residents’ financial interests were safeguarded by the home’s practices and procedures for looking after money on their behalf. There were comprehensive health and safety systems in operation to ensure the ongoing welfare of both residents and staff. EVIDENCE: Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 24 The Registered Manager works in the home for the majority of the working week and there is evidence of good day-to-day contact between the manager and the staff and the residents. The staff were confident of the mangers skills and his ability to support positive changes in the home. The manager has an open door policy and approach to managing the home, supporting the care staff and providing daily contact. The staff felt well supported in their roles and any issues identified were dealt with as they arise. The manager had spent individual time with the staff in support of their NVQ, and boosted their morale and motivation when there had been a high turn over or absence of staff. All of the staff stated that the atmosphere in the home has greatly improved and stated “it is now a pleasure to work here” and “the manager is fair but firm and is approachable”. Residents spoke highly of the manager and a warm relationship between them was observed. Staff confirmed they also received regular formal supervision, which related to good care practice and continuing professional development, supervision files reflected this. The home has developed a quality assurance system that has been implemented. The residents and representatives are involved in the user surveys and the information gathered from those surveys has been used to enhance residents’ lifestyles within the home. The home plans to survey the staff working in the home. The home uses an independent consultant in the process following which a report had been produced summarising the outcomes and making a number of recommendations. The manager provided evidence that action had been taken following the findings and recommendations. Four resident personal allowance records were sampled. All four sets of records were accurate and well maintained. The money held in the home for residents is held in a safe in a locked room. As previously reported the home does not act as appointee for any resident living there. The residents’ families are responsible for the financial matters of individual residents. The home now provides staff with appropriate Health and Safety training. The manager was aware of relevant Health and Safety legislation and was committed to the welfare of both the residents and staff group. Evidence indicated that checks are routinely carried out in the home including: fire equipment checks, fire drills, and certified equipment checks by qualified professionals. The manager maintained a record of all checks and servicing carried out on equipment and utilities, providing evidence that the equipment and premises were regularly maintained. Hot water, and fire alarm checks were not accurate or up to date. The staff spoken with were committed to the safety of the residents and were able to identify the potential hazards in the home. The staff stated that they would report any safety hazard to the Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 25 manager who would then take the appropriate action. The staff also confirmed that they would use the resident risk assessment to ensure the safety of the residents. Staff were aware of Health and Safety issues around the home and wore personal protection clothing when needed. Safe practice is also maintained through the homes policies and procedures, the information available on individual care plans (e.g. risk assessments) and the risk assessments carried out on the premises. The manager had a sound knowledge of Health & Safety issues and was compliant with the legislation relevant to the home, residents and staff. The home has a number of relevant safety notices posted throughout the premises. The hot water temperature checks are not carried out on a weekly basis. Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 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 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Timescale for action It is required that care plans are 31/12/06 developed further to ensure that they contain clear details of the action required to meet each residents individual needs (physical and mental health and social/recreational needs). The care plans must reflect the special needs and care for residents with dementia. The care plan daily records must reflect the care given. This is a repeat requirement for the third time (last timescale 31/03/06). 2. OP7 14 (2) 12 (1) The registered person must 31/12/06 ensure that all residents have an accurate and up to date risk assessment that identifies both risk and the action required to address the risk. The registered person must 31/12/06 ensure that the medication administration records are accurate and up to date. The registered person must 31/12/06 ensure that a formal programme DS0000017911.V316797.R01.S.doc Version 5.2 Page 28 Requirement 3. OP9 13 4. OP12 14 (2) Poplars 5. OP28 14 (2) (a) 6. OP30 18 and 13 of activity is maintained paying particular regard for those residents with dementia. The registered person must 30/04/07 ensure that 50 of the staff team achieve the NVQ Level 2 award. The registered person must 30/04/07 ensure that all staff must receive regular training updates in the Protection of Vulnerable Adults. All staff must be provided with the appropriate Safeguarding Adults documentation. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP27 Good Practice Recommendations The registered person should closely monitor the number of long days worked by some staff, and ensure that the length and pattern of their working week does not affect their capacity to safely fulfil their responsibilities. The registered person should ensure that internal checks on fire alarms, emergency lighting, and hot tap water temperatures are regularly carried out and recorded. 8. OP38 Poplars DS0000017911.V316797.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. 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