Inspection on 25/09/07 for Poplars

This inspection was carried out on 25th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Poplars 16/10/06

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 Unannounced Inspection 25th September 2007 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.V352066.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.V352066.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.V352066.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 16th October 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. On the day of the site visit the charges per week are as follows: £367.15 - £419.00. Poplars DS0000017911.V352066.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced ‘key’ site visit. At the site visit a tour of the premises took place, care records, staff records, medication records and other documentation were selected and examined. Time was spent talking to, observing and interacting with people living at the home, and talking to staff. Prior to the site visit the home had completed and sent in to CSCI their Annual Quality Assurance Assessment (AQAA). This outlines how the home feel they are performing against the National Minimum Standards, how they can evidence this, and their plans for improvement. Prior to this site visit a selection of surveys with addressed return envelopes had been sent to the home to give to people living there, their relatives and staff. On the day of the inspector’s visit the atmosphere in the home was relaxed and welcoming and the inspector was given every assistance from the manager and care staff. The inspector would like to thank the manager, staff team, residents, and relatives for their help throughout the inspection process. What the service does well: People choosing to move into the home have their need thoroughly assessed to make sure that the home can give them the care that they require. The home provides a good standard of care and support to people with a range of needs, the staff have a good understanding of what care people require to make them comfortable and safe. Policies and procedures relating to protection and the home’s medication system are well managed. A good standard and choice of food is provided by a cook who involves the people living in the home in the selection of menus. Meal are varied, well presented and nutritionally balanced. People living in the home made a number of positive comments regarding how they are treated by staff, their experience of living in the home, and how their needs and wishes are met at Poplars. Poplars DS0000017911.V352066.R01.S.doc Version 5.2 Page 6 People are provided with activities on a daily basis but there is no pressure on them to take part. People have flexible routines that they control and spend their time doing as they choose. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Poplars DS0000017911.V352066.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 DS0000017911.V352066.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 group is good. This judgement has been made using available evidence including a visit to this service. People choosing to live in Poplars have their needs assessed before they move into the home. They also have the opportunity to view the home and meet the staff before they move in. EVIDENCE: Southend Care employs a placement co-ordinator who undertakes all preadmission assessments for people choosing to live in the home. There is documentation in care plans that confirm that peoples needs and wishes have been identified and discussed before the home decides whether it can provide the care that the person will need. People living in the home confirmed that they felt that they had received a good level of information about the home before moving in. Poplars DS0000017911.V352066.R01.S.doc Version 5.2 Page 9 The files of two of the newest people moving into Poplars confirmed that a preadmission assessment was completed and the content of these assessments was detailed. When required there was information available from Social Services in the form of a professional assessment. The information gathered at the assessment is used as the basis of the person’s care plan. Intermediate care is not provided at Poplars. Poplars DS0000017911.V352066.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10: Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. The care plans and risk assessments used in the home remain insufficient and do not provide a full range of information to staff. This lack of information has the potential of placing residents at risk. The healthcare needs of people are addressed and recorded. The medication systems in the home ensure the safety of the people living there. The home provides a service that treats individuals with respect, and staff demonstrated a good understanding of peoples needs. EVIDENCE: Southend Care introduced a new style care planning system in June 2007 that is being used in Poplars. The format of these care plans will, when completed properly, be a useful working document for staff. The four care plans looked at Poplars DS0000017911.V352066.R01.S.doc Version 5.2 Page 11 on the day of the visit did not contain enough detailed information to guide staff on how best to care for people. The current needs of two individuals had not been identified in enough detail, and there was little information on the type of care that staff needed to provide for these people. Risk assessments also need more information than they currently contain. These issues were discussed with the manager and the senior staff on the day and it was agreed that all care plans would be reviewed and updated by the end of 2007. The information written in care plans confirmed that people living in Poplars have access to health care professionals and services. Records provided evidence that GP’s, district nurses, chiropodists, dentists, and community nurses are involved in the care of people living in the home. The information regarding people’s personal care needs was not clear and did not give staff enough information for them to give people the care that they want. Staff spoken with said that they are aware of people’s health care needs and will make contact with the health services when a persons needs change. The home undertakes nutritional assessments for residents, and maintains good nutritional records. Training records showed that most staff had undertaken training in relevant health care issues such as incontinence care. One person said, …”if I feel ill the staff are on the phone to my GP getting advice”, and …”carers are always asking me if I am well, they keep an eye on me”. Medication in the home is well managed and is audited by a local pharmacist. The medication administration records used in the home are accurate and up to date, as are the records of receipt and disposal of medication. All drugs are securely stored and well organised. Evidence was seen to show that staff that administer medication have received appropriate training. From watching staff on the day of the visit and from speaking with people living in the home it was clear that people are treated with care and respect. One person said that staff …“are so kind and caring, they treat us like family” and …“carers cannot do enough for us and they always have a bit of time for me”. Poplars DS0000017911.V352066.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15: Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. People living in Poplars can expect to have flexibility and choice with regard to their daily lives. Their expectations and preferences with regard to lifestyle are met. People living in the home are provided with a varied and appetising choice of meals. EVIDENCE: Since the previous inspection Poplars has introduced a formal programme of activity for people living there. On the day of the visit people in the home were taking part in ‘exercise to music’ and appeared to genuinely be enjoying the activity. People were laughing and joking and contributing to the morning’s activity. Generally staff are aware of the need to support peoples’ social, emotional, and communication skills. People living at the home are spoken with and listened to about their choice of daily activities where possible. People spoken with said they …”enjoyed the events organised by the home…we have a laugh” and …”there is always something to get involved in if you want”. Poplars DS0000017911.V352066.R01.S.doc Version 5.2 Page 13 People were observed moving around the home and involving themselves in activities and routines they felt happy and comfortable doing. People are free to spend time in their bedrooms or with others in communal areas throughout the home. The home’s kitchen was briefly inspected at the site visit. The kitchen continues to maintain a high standard of hygiene. The quality of the meals also remains good, people spoken with are very complimentary of the quality of the food. One person spoken with said,”the food is lovely, we get a nice choice and the meals are always tasty”, and …”sometimes there is too much to eat, and the food is well cooked and tastes lovely”. The catering staff spoken with at the site visit were very experienced and said that they had undertaken training in the nutritional needs of older people. The staff were friendly and committed to making meals and mealtimes a pleasurable experience. Poplars DS0000017911.V352066.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18: Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. Overall people can be sure that any concerns they raise will be listened to and may be confident that they will be cared for in a way that protects them from abuse. EVIDENCE: There had been no changes made to the home’s complaints and protection policies, procedures and guidance since the previous inspection. The complaint procedure is written in plain language and people are able to understand it. All of the people spoken with confirmed that they were aware of the Complaint procedure, and they were able to say that they knew who to complain to: either a senior member of staff or the manager who they were able to name. The complaint log was examined and was not accurate. The log recorded 3 complaints raised since the previous site visit. The CSCI had received information regarding a forth complaint but this had not been recorded in any document held within the home. This issue was discussed on the day with the manager who agreed that any concerns raised by either someone living in the home, a relative or representative would now be documented in the complaint log. The complaint log was examined and was accurate and well maintained. Examination of records, policies and procedures showed that steps are taken to protect people living at the home from abuse. The home has copies of the Poplars DS0000017911.V352066.R01.S.doc Version 5.2 Page 15 local authority’s written adult protection guidelines for staff. Staff spoken with on the day were clear about what to do if an allegation of abuse were made. The majority of the staff team have received training around how to protect vulnerable people in their care, and all staff took this issue very seriously. The manager and senior staff were aware of the procedures to take should an allegation of abuse be raised. People living in the home trusted the staff to act on their behalf should they need them to and said…”I feel safe here and the staff will always look after me” and …”the staff are trustworthy and would not do anything to upset us”. Poplars DS0000017911.V352066.R01.S.doc Version 5.2 Page 16 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 group is good. This judgement has been made using available evidence including a visit to this service. Overall the home provides a safe, well-maintained environment, which on the day of the site visit was clean and hygienic. The home, and therefore the people living in it would benefit from having a planned programme of re-decoration and renewal. EVIDENCE: As of the previous inspection the home appeared safe and clean, however as stated in the previous inspection report, various areas in the home were in need of re-decoration and new carpets. The manager presented bedrooms that had been re-decorated and re-carpeted since the previous site visit. The manager oversees the maintenance and safety of the premises and has access to maintenance services if and when required. The bathrooms and toilets appeared tired, old and institutional and would benefit from some investment, Poplars DS0000017911.V352066.R01.S.doc Version 5.2 Page 17 as would the majority of the hallways. Communal lounges are large and due to this do not feel homely. The home has a secure garden area, which is well maintained and laid out. People living in the home did mention that some parts of the home …” could do with a lick of paint” and …” if it were home we wouldn’t keep it like this”. Despite this fact, the decoration in the home did not appear to bother the people living there. People were more interested in reporting that they felt that they had a …”great life” in Poplars. As of the previous inspection report 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. Infection control policies and procedures were not reviewed on this inspection; protective clothing was seen to be available to care staff. Poplars DS0000017911.V352066.R01.S.doc Version 5.2 Page 18 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 & 30: Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. The home provides people living there with an experienced and qualified staff team, in sufficient numbers to make sure that their needs are met. Poplars recruitment practices are robust and help ensure the protection of people living there. EVIDENCE: The staff rota was examined and showed 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. It was noted that on occasion staff are working two long shifts in a row, staff spoken to were very clear that this was their choice. As of the previous inspection report the manager was advised that he must monitor this closely to ensure the health, safety and welfare of both staff and people living in the home 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. Staff working in the home receive a programme of training that includes dementia, manual handling, safeguarding adults, first aid, and infection control. Staff spoken with on the day said that they have received training that they feel is right for the job that they do. One member of staff stated that…” I Poplars DS0000017911.V352066.R01.S.doc Version 5.2 Page 19 am really happy with the training I get here” while another said,…” the training is good and it helps me see good and bad practice”. Of the 16 current staff group: 6 have achieved the NVQ Level 2 or above, 3 members of staff are currently undertaking the course and 3 members of staff have wavered the opportunity to take up the training, the remaining 4 members of staff are yet to apply for the training. The files of three members of staff were looked at during the course of the inspection and contained the checks and information required before allowing staff to start work at the home. Files also included training, supervision and employment records. Staff confirmed that they had to wait for all of the security checks to be made before starting work in the home and said…”I did not mind waiting as I know that it is a way to make sure that they are employing the right people” and …”the home was really thorough and asked lots of questions on my interview”. People living in the home and others have stated how …“friendly and kind” the staff are as well as being …“hard working, dedicated and caring”. Poplars DS0000017911.V352066.R01.S.doc Version 5.2 Page 20 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 & 38: Quality in this outcome group is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run in the best interest of the people living there. EVIDENCE: The registered manager is qualified, competent and has the necessary skills to run the home efficiently. Staff and people in the home made positive comments regarding the skills of the manager and his ability to resolve any issues quickly and professionally. The manager does undertake quality assurance monitoring and uses the information gained to inform care practice. This information will also be assimilated into the home’s annual report. Poplars DS0000017911.V352066.R01.S.doc Version 5.2 Page 21 Residents’ money was checked with the manager and was correct. Money is held securely and accounted for properly. Safety certificates were checked and are up to date. Records relating to the health and safety of individuals living and working in the home were generally well maintained with appropriate training undertaken by staff in safe working practices. Poplars DS0000017911.V352066.R01.S.doc Version 5.2 Page 22 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 2 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 2 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Poplars DS0000017911.V352066.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Timescale for action It is required that care plans are 31/12/07 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. The home must make sure that 31/12/07 all residents have an accurate and up to date risk assessment that identifies both risk and the action required to address the risk. This is a repeat requirement. All complaints received at the 31/12/07 home must be recorded in the complaint log to ensure that there is a clear trail of evidence that shows that the home deals with complaints in a clear and professional manner. Requirement 2. OP7 14 (2) 12 (1) 3. OP16 18 (1) (2) Poplars DS0000017911.V352066.R01.S.doc Version 5.2 Page 24 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. To make peoples’ experience of living at Poplars more pleasurable the home would need to improve a number of areas by way of redecoration and renewal. 2. OP19 Poplars DS0000017911.V352066.R01.S.doc Version 5.2 Page 25 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. Extracts may not be used or reproduced without the express permission of CSCI Poplars DS0000017911.V352066.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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