Inspection on 22/07/05 for Poplars

This inspection was carried out on 22nd July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 01/12/08

Poplars 11/01/08

Poplars 09/02/07

Poplars 29/11/05

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 15 Ickenham Road Ruislip Middlesex HA4 7BZ Lead Inspector Susan Woolnough-Singh Unannounced 1 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Poplars G61-G10 s27119 Poplars v214406 010705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Poplars Address 15 Ickenham Road, Ruislip, Middlesex HA4 7BZ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01895 635 284 Appcourt Limited Trading as: The Poplars Ms Debra Fairholme Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Poplars G61-G10 s27119 Poplars v214406 010705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 27th January 2005 and 11 February 2005 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 twenty-four of them have en suite facilities. A new staff room and laundry have been built to the rear of the property since the last inspection. Two new single bedrooms have also been provided at the rear of the buidling on the ground floor. The number of service users accomodated has not changed. Poplars G61-G10 s27119 Poplars v214406 010705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the unannounced inspection of Poplars Care Home. The last inspection took place on 27/1/05 and 11/2/05. Eight requirements were made at the last inspection. The timescale for four requirements had been met. The time scale for four requirements had not been adhered to. As part of the inspection process the inspector spoke with three service users individually and two service users who were part off a group. One member of staff was spoken with at length. A number of key standards were assessed during this inspection. Key standards not assessed will be assessed at the next inspection. What the service does well: What has improved since the last inspection? What they could do better: Although the general environment of the home is good, extra care needs to be taken with odour control in some areas. Formal management monitoring Poplars G61-G10 s27119 Poplars v214406 010705 Stage 4.doc Version 1.30 Page 6 systems in the home must be improved and the Provider must be able to demonstrate this. 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. Poplars G61-G10 s27119 Poplars v214406 010705 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Poplars G61-G10 s27119 Poplars v214406 010705 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 2 3 The Statement of Purpose and Service Users Guide provide clear information about the home for prospective service users; this could further be improved by being made available in large print. Service users are assessed prior to admission to ensure that their needs can be met. Service users are provided with a statement of terms and conditions. The Provider needs to ensure that the format of this complies with standard 2 of the National Minimum Standards. EVIDENCE: A Statement of Purpose and Service Users Guide are available. These form part of the same booklet. The information contained in the Guide complies with the standard. The information is clear and well presented. An improvement could be made to the Guide by ensuring it is provided to older people in large print, the print is quite small in some part of the Guide. The Statement of Terms and Conditions must be amended to include the elements of care and residency outlined in standard 2. This was a requirement of the last inspection. Poplars G61-G10 s27119 Poplars v214406 010705 Stage 4.doc Version 1.30 Page 9 One new service users has moved in to the home since the last inspection. A Needs Led Assessment from the placing local authority and an admission assessment completed by the home were available. Poplars G61-G10 s27119 Poplars v214406 010705 Stage 4.doc Version 1.30 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 standard(s) 7 8 10 A requirement was made at the last inspection for care plans to be presented with more information regarding holistic needs. The three care plans sampled demonstrated that this had been done. Service users spoken with were generally satisfied with the care offered to them by staff. EVIDENCE: Three service users care plans were sampled. The care plans cover all the areas of daily living and any additional needs. Care plans also cover any health issues that need to be monitored. There was evidence on one service users file that mental health issues were being monitored and logged. The purpose of this being that the information could be presented to the relevant health care professional. There was a record of visits to and by health care professionals such as the GP and Chiropodist. The care plans sampled had been reviewed in May or June. The content and detail of the care plans had improved since the last inspection. Service users were spoken with regarding their health needs and personal care needs. One service did not have any particular identified health needs; one Poplars G61-G10 s27119 Poplars v214406 010705 Stage 4.doc Version 1.30 Page 11 service user felt his/her needs were being addressed and monitored by the home. Service users commented that if they needed help with personal care assistance was given. Two service users said they liked to be independent in s with personal care and this was respected. The Inspector spoke with a member of staff regarding care plans and health. A link worker system is in place. Staff monitors general physical health and well being when they are assisting with personal care. The services users and their families also communicate with staff is there are any health issues. Senior support workers are informed by care staff, of any changes in service users health. Poplars G61-G10 s27119 Poplars v214406 010705 Stage 4.doc Version 1.30 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 standard(s) 12 13 Service users spoken with indicated that they were satisfied with the care they received in the home. Friends and family visit informally and are able to spend time in private with service users if they wish. EVIDENCE: Service users were spoken with regarding their perception of life in the home and arrangements for visitors. The information given to the Inspector was brief, but service users generally said that they were comfortable in the home and were generally complimentary about staff. One service user said that information on visiting was in the brochure and that family friends may visit whenever they wish although visiting is not encouraged at meal times. Poplars G61-G10 s27119 Poplars v214406 010705 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home has a clear complaints procedure, which is included in the service users guide. EVIDENCE: A complaints procedure is contained in the Service Users Guide. This is clearly set out and contains information on how to contact the National Care Standards Commission. The information on complaints should be amended to include Commission for Social Care Inspection. No complaints had been received by the home at the time of the Inspection. One-service user spoken with could not remember seeing the complaints procedure but said he/she would know whom to approach if there was a concern. Poplars G61-G10 s27119 Poplars v214406 010705 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 26 EVIDENCE: A new extension has been completed since the last inspection. This consisted of two new bedrooms on the ground floor to the rear of the home and a new lounge, which replaces the conservatory. New furniture had been purchased for the lounge extension. The dining room is now located in the space which was formally a seating area, the new dining room is in close proximity to the kitchen. The communal space in the home has been improved. A new building in the garden now houses the staff room and the laundrette. Chair covers in the first lounge were in need of washing or replacing, information was given that plans had already been made to address this and new chairs were to be purchased. At the time of the inspection there was a strong smell of urine in the ground floor corridor near the lounge dining room area. The Registered Manager was aware of this and said that she had tried to address this. The Registered Manager was also informed of a bedroom that had a similar strong odour. A tour of the building took place all of the bedrooms and en suite facilities were seen, apart from the one room already identified, these were Poplars G61-G10 s27119 Poplars v214406 010705 Stage 4.doc Version 1.30 Page 15 found to be in a satisfactory with regards to hygiene standards. The home has an infection control policy, which is displayed in the home. Poplars G61-G10 s27119 Poplars v214406 010705 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 29 30 Satisfactory systems for the recruitment of staff are now in place. The Registered Manager was able to demonstrate that a commitment had been made to the development and training of staff. EVIDENCE: The roster for the week of the inspection was examined. This was found to be satisfactory. The minimum staffing level for Poplars is four care workers and one senior care worker on the morning shift and three care workers and one senior care worker on the evening shift. Two waking night staff are on duty overnight. The situation with the new launderette, which is in the rear garden, will have to be monitored, as night staff who attended to service users laundry are no longer doing this due to the location. This is placing an additional strain on the day staff. The recruitment procedure has been improved since the last inspection. A requirement was made that the Registered Manager does not interview staff alone. The Registered Manager is now selecting and interviewing prospective new staff with a senior care worker. The Registered Manager commented that she aims to recruit and retain staff with an NVQ in Care; this is not always possible. A programme of NVQ training is available for staff. The Registered Manager is undertaking the Registered Managers Award, three staff are undertaking NVQ Level 3 and five staff NVQ Level 2. Induction training for new staff comprises of an induction checklist, video training on safe working practices and shadow working with experienced members of staff for three to Poplars G61-G10 s27119 Poplars v214406 010705 Stage 4.doc Version 1.30 Page 17 four days. TOPPS Induction and Foundation training books had been ordered; new staff will therefore complete induction training to National Training Organisation workforce standards. Refresher training in Moving an Handling had been booked for staff at the end of July. An Employee Training Plan for 2005/6 was available. Fire Training, Assessors Training, Train the Trainer, and First Aid training had been planned. Poplars G61-G10 s27119 Poplars v214406 010705 Stage 4.doc Version 1.30 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 34 37 The evidence gained from this inspection indicated formal systems were not in place for monitoring the running of the home. Two requirement timescales had not been met from the last inspection. EVIDENCE: A requirement was made at the last inspection for a Quality Control System to be implemented at Poplars Care Home. The Providers had met with three companies to possibly select a Quality Control System for the home. A record of the monthly-unannounced visits by the provider to the home (Regulation 26 visits) are not being forwarded to CSCI, therefore there is no evidence that these are being carried out. A requirement was made at the last inspection for a current financial statement to be made available, the time scale for this had not been adhered to, a Company Financial Statement had not been forwarded to CSCI. A requirement was also made for a photograph of each service user to be included as part of their records, the time scale for this had not been Poplars G61-G10 s27119 Poplars v214406 010705 Stage 4.doc Version 1.30 Page 19 met. Information was given that a photograph for the records would be taken at a future garden party. Poplars G61-G10 s27119 Poplars v214406 010705 Stage 4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 2 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 2 2 x x 2 x Poplars G61-G10 s27119 Poplars v214406 010705 Stage 4.doc Version 1.30 Page 21 Yes 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 3 Regulation 5 (1) (b) (c) Requirement The Terms and Conditions must contain the inforamtion stated in 2.2 National Minimum Standards. The timescale given at the last inspection of 1.7.05 had not been met. The oudour identified on the ground floor must be identified and eliminated. The odour identified in relation to one of the dervice users bedrooms must be identified and eliminated. A quality assurance and monitoring system must be in place in order that a review of the qulaity of care provided take place. (Previous timescale of 1.7.05 not met) The provider must visit the home once a month and report to CSCI in writing. A current financial statement must be made available to CSCI. (Previous timescale of 1.7.05 had not been met.) A photograph must be made available for each service user who residens in the home. This will be part of their personal record.. (The timescale of Timescale for action 1.9.05 2. 3. 26 26 23 (2) (d) 23 (2) (d) 1.10.05 1.10.05 4. 33 24 1.9.05 5. 6. 33 34 26 25 (2) 1.9.05 .1.9.05 7. 37 17 1.9.05 Poplars G61-G10 s27119 Poplars v214406 010705 Stage 4.doc Version 1.30 Page 22 1.5.05 had not been met. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 1 16 27 Good Practice Recommendations The Statement of Purpose and Service Users Guide should be provided in large print. The complaints procedure should amended to include CSCI. The management of the launderette should be monitored. 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