Inspection on 26/07/06 for Poplars

This inspection was carried out on 26th July 2006.

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 no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Poplars 18/08/08

Poplars 04/07/07

Poplars 27/10/05

Poplars 25/05/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Poplars 123 Regent Road Hanley Stoke on trent Staffordshire ST1 3BL Lead Inspector Jane Capron Key Unannounced Inspection 26th July 2006 09:30 Poplars DS0000064016.V303572.R01.S.doc Version 5.2 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 DS0000064016.V303572.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 Adults 18-65. 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 DS0000064016.V303572.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Poplars Address 123 Regent Road Hanley Stoke on trent Staffordshire ST1 3BL 01782 209410 01782 269187 chris@delamcare.co.uk 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) Delam Care Ltd Miss Tracy Anne Baddeley Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (6) of places Poplars DS0000064016.V303572.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th October 2005 Brief Description of the Service: The Poplars is a six-bedded care home owned by Delam Care Limited, a company owned by Care Tech. It is located in Hanley in an area with a number of similar care homes owned by the same company. The Poplars provides a service to people of either gender with a learning disability although some may also have mental ill health. The home is one of three adjoining homes that are managed by one Care Manager. The homes have their own core staff members but absences and staff vacancies are covered by staff from the other homes or from other staff from within the company. The Poplars is in an urban area close to Hanley park and Stoke on Trent College. It is located within a twenty-minute walk to the shopping and leisure facilities of Hanley. The service users access a range of college courses and undertake social activities and holidays. The six homes in the area access two people carriers and the service users contribute to the running of these vehicles. The home has one care staff member on duty at all times and its aim is to provide service users with support, encouragement, supervision and monitoring in order to enable them to live as independent a life as possible. The fees are £297 - £387 per week. Poplars DS0000064016.V303572.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 inspection that took place over a five-hour period. The inspection included discussions with residents to find out about their experiences of living in the home. Discussions took place with the staff member on duty and with the Care Manager. A sample of records relating to the care of the residents was looked at. The arrangements for the administration of medication and for safeguarding residents’ money were examined and a range of documentation relating to Health and Safety was looked at. The recruitment and selection process and the training provided to staff were looked at by sampling a number of personnel files. The inspection included looking at the accommodation including all of the bedroom accommodation and the communal rooms. Since the last inspection no additional visits have taken place and there have been no complaints. What the service does well: Residents said that they liked living at the home and generally got on well together. They said that they got on with staff and that staff were supportive and listened to them. Residents made comments such as ‘I like living here’ and that ‘we are well looked after’. Residents liked their bedrooms and they were well personalised with lots of personal items including photos, ornaments and pictures. Bedrooms were all lockable and most residents locked their bedroom. Residents were involved in a number of tasks related to the running of the home including planning meals, food shopping, keeping their bedroom clean and tidy and helping with aspects of meals such food preparation and laying the table and washing up. Residents all had attended college several times a week during the last college year. Courses included floristry, art and drama, gardening as well as learning personal presentation and independent living skills. The home had a good admissions procedure that included prospective and current residents. The home included prospective residents in the assessment process and they were expected to visit the home to get to know the residents and routines before making a decision to move in. Poplars DS0000064016.V303572.R01.S.doc Version 5.2 Page 6 Support plans fully identified the needs of residents, and the resident and the key worker internally reviewed these. The home had developed a range of individual risk assessments that showed the level of support needed to support residents to undertake tasks such as bathing and going into the community. Residents’ health care needs were being met. Residents had a local GP and attended for health checks and outpatient appointments. The home was aware of issues relating to the sensory needs of a resident and an interpreter was used to aid help with communication when attending for hospital appointments. What has improved since the last inspection? What they could do better: The home did need to undertake some actions to fully meet the standards and to improve the service to the residents. There were a few gaps in a medication chart and the home needed to ensure that all medication administered was correctly recorded. In addition all staff needed to have suitable training in medication particularly as they work alone in the home. Most of the staff had been trained in adult protection but this needs to be provided to all staff. The home still needed to ensure it had sufficient staff on duty to support residents to undertake a range of activities. The home’s accommodation was suitable for the residents but the home needed to repair the rear yard as t was very uneven in places and was a hazard to residents and staff. The accommodation would be improved if the upstairs bathroom was upgraded and decorated. Whilst the home was clean and tidy and had hygiene procedures in place the walls in the laundry needed to be made easily cleanable and the cleaning equipment should not be kept in the kitchen. The home had a fire action plan in place following a check by the fire service and this must be completed as scheduled. Poplars DS0000064016.V303572.R01.S.doc Version 5.2 Page 7 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 DS0000064016.V303572.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Poplars DS0000064016.V303572.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s admission procedure ensured that prospective residents’ were involved in the assessment process and had the opportunity to visit the home in order to make a decision about whether they wanted to move to the home. The residents’ rights and responsibilities were identified in a contract provided to residents. EVIDENCE: The home admission procedure ensured that assessments were completed before a decision was made to admit a resident. Assessments were completed by both the local authority and by the manager of the home. The home met prospective residents to undertake the assessment with them. The assessment included prospective residents’ health and personal care and social and leisure needs. The home was in the process of admitting a new resident and the home had been involved in review meetings and the prospective resident had visited the home twice. Further visits were arranged for the person to get to know the home and the other residents prior to deciding to move to the home. Discussions with several residents confirmed that they had met the prospective resident. They were able to give their views over whether they felt that the prospective resident would get on with them. Poplars DS0000064016.V303572.R01.S.doc Version 5.2 Page 10 All residents were provided with contracts both by the local authority and the home. These outlined the home and the residents’ rights and responsibilities. The contracts showed the room that a resident would occupy. Poplars DS0000064016.V303572.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s support planning process ensures that residents’ needs are identified and that residents are involved in reviewing their plans. The residents are encouraged to make choices and to take part in practical activities related to the running of the home. EVIDENCE: Sampling of files showed that the home had developed support plans. These included residents’ health and personal care needs, their educational needs, their social and leisure needs and needs relating to financial management. Where required needs relating to communication needs and sensory disability were identified. Residents subject to the Care Planning Approach had been reviewed. The support plans were up to date and had been internally reviewed between the resident and their key worker. The home had developed a range of individual risk assessments. These included access to the community, use of kitchen equipment, smoking, Poplars DS0000064016.V303572.R01.S.doc Version 5.2 Page 12 managing money, managing hot surfaces and hot water and bathing. Risk assessments were being reviewed. Residents confirmed that they were able to choose how and where to spend their time. Residents said that they had chosen to go to college and were able to decide which courses they wanted to attend. One resident said that she chose when to go out either to see friends or to go shopping but she needed to let the staff know. All residents said that they helped to plan meals and that if they did not want a meal they could have an alternative. Residents had recently been on holiday and they said that they had had a meeting to choose where to go. They also said that they meet to choose what activities they wanted to take part in. The home supported residents to manage their money and several residents said that they had decided to have a certain amount each week whilst saving the rest. One resident explained how she had chosen to spend money and showed the items she had bought. Sampling of residents’ finances showed that the home’s procedures were safeguarding residents’ money. Accurate records and checks were in place and receipts supported expenditure. One resident confirmed that they had an advocate who gave them support with decision-making. Residents were involved in a range of tasks related to the running of the home. Residents said that they helped to clean their bedrooms, helped with the weekly food shopping including going to the local shop for milk and bread, helped to wash up and lay the table and help to plan meals. Residents said that they had regular resident meetings where such issues as meals, activities and any problems were discussed. Poplars DS0000064016.V303572.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents had the opportunity to take part in educational activities and some leisure and social activities in and out of the house although this should be further developed. The home provided the residents with a varied menu that was based on their choice. EVIDENCE: Five of the residents have been attending college this academic year. Courses include floristry, painting and decorating, gardening, jewellery making, personal presentation and art and drama. One resident had attended the gym at college. The company provided staff to support college attendance. One resident had part time work at an older person’s home. All of the residents access the community. They attend community health care services. Most of the residents went shopping on a regular basis walking into Hanley. Several of the residents said that they visited friends at nearby care homes. The home also on occasions organised trips to the theatre. The home Poplars DS0000064016.V303572.R01.S.doc Version 5.2 Page 14 had shared use of two people carriers. The residents pay a monthly rate to use the vehicles. Residents said that the home organised some activities in the home. These included beauty evenings where staff undertook manicures and sometimes board games. The residents also said they helped to keep the garden tidy and occasionally went out for meals and to the pub. Residents said they liked watching the TV particularly the ‘soaps’. The residents that wanted it had TVs in their bedrooms and spent time both in the communal lounge and in their bedrooms watching TV. Some of the residents needed a lot of encouragement to take part in activities and due to the staffing level of one staff member on duty who also had to undertake cleaning and catering the amount of time available to provide such support was limited. In addition the residents could not go out with staff support unless all residents wanted to go unless additional staffing was arranged or the Care manager was available to come to the home. Most of the residents had been on holiday recently to Blackpool. Residents said they enjoyed this. Residents paid for their own holiday. The residents paid for the accommodation whilst the home paid for the staffing costs. Residents were supported to maintain appropriate relationships with family and friends. Several residents said they visited friends at the nearby care homes and several said they saw their relatives. The home’s daily routines were quite relaxed. Residents said they could get up when they liked, depending on their agreed schedule, and go to bed when they wanted. Several chose to go to bed quite early and watch TV in their bedroom. Residents were observed using the communal rooms and accessing their bedrooms throughout the day. There were no fixed times for meals although they were held within a time framework. The home had a ‘no smoking’ policy and any residents that smoked did so in the rear yard. Residents said they liked the food served and that they were involved in choosing the meals and doing the food shopping. One resident stated that she helped with meal preparation for example preparing vegetables. All residents helped with laying and clearing the table and with the washing up. Meal times were a social occasion where residents met together with the staff member on duty to talk about topical issues. Examination of the menus showed that the home provided residents with a varied menu. Breakfast consisted of cereals and toast that residents had when they got up. A light lunch was provided that consisted of things like sandwiches, pizza or something on toast. The main meal was held in the early evening and provided residents with a full meal and a pudding. A supper was also provided. Yoghurts, fruit and biscuits were available throughout the day. Poplars DS0000064016.V303572.R01.S.doc Version 5.2 Page 15 The home provides a relatively low budget for food approximately £17 per person a week and examination of food stocks at the home showed a lot of ‘own brands’ and ‘value’ products. The home’s records showed that residents’ weight was being monitored monthly. Poplars DS0000064016.V303572.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,18,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was meeting the health and personal care needs of the residents. The home had a suitable medication procedure but needed to ensure that all staff had suitable medication training and that there were no gaps in the medication administration records in order to ensure that residents’ medication needs are fully met. EVIDENCE: The health care and personal care needs of residents were fully identified in the support plans. Most residents needed some encouragement and support to manage their own personnel care needs. Residents needed assistance with some hair care tasks and nail care. Residents said that staff helped them with these tasks and one resident said that a staff member had recently manicured her nails and applied nail polish. Residents said that staff respected their privacy always knocking on bedroom doors. Residents said they went shopping to buy clothes. One stated that staff supported them to go shopping. The home involved specialists as needed including psychiatric services and one resident had received an assessment for equipment relating to sensory needs. Several of the residents had the support of a Community Psychiatric Nurse and attended review meetings with a psychiatrist. The home had a key worker Poplars DS0000064016.V303572.R01.S.doc Version 5.2 Page 17 system in place and support plans were reviewed by the resident with the key worker. Residents’ healthcare needs were being met. They all were registered with a local GP and they confirmed that they attended for eye and dental checks and received chiropody treatment. All healthcare appointments were recorded in the support plans. One resident with sensory needs had an interpreter for all hospital appointments. Residents were receiving the necessary health screening and follow up appointments. The home operated a monitored dosage system of the administration of medication. The medication procedure was signed by all staff. All staff administered medication and received some in-house training prior to taking on this role. Most staff had undertaken a comprehensive training in the safe administration of medication and this needs to be completed by all staff as soon as possible after starting work at the home. The medication was kept securely in a locked cupboard. An examination of the records showed gaps on one occasion. One resident was self-medicating on a daily basis. The home had completed an assessment, which was reviewed. Discussion with this resident confirmed that the resident was aware of when to take medication. The resident had a lockable box in which to keep the medication and kept the bedroom door locked. Poplars DS0000064016.V303572.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents felt listened to and were confident that staff would deal with any concerns they raised. The home’s procedures in adult protection were contributing to keeping residents safe but the home needed to ensure all staff had knowledge in adult protection issues. EVIDENCE: The home had a complaints procedure in place and this was displayed in the entrance hall. The home maintained a record of complaints. Residents said they were aware of how to complain and were confident that staff would sort out any problems they raised. They said that they had the opportunity to raise issues individually or through the resident meetings. All residents had been given a service ser guide that provided information about the complaints procedure. The home had links with the advocacy service and involved them with residents when needed. The home had an adult protection procedure in place. The company provided training for staff and most of the current staff had completed this training providing them with information over signs of abuse and how to respond to concerns. Residents said that they felt safe at the home. The home had robust procedures in place to safeguard residents’ finances. Poplars DS0000064016.V303572.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,27,28,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’ accommodation provided residents with satisfactory communal and private accommodation apart from the rear yard which was a hazard to residents and staff. The residents’ benefited from a home that was clean and tidy and that had infection control procedures in place but the home needed to ensure that cleaning equipment was appropriately stored and that the laundry was decorated in a way that would reduce the likelihood of the spread of infection. EVIDENCE: The premises are a Victorian detached property that is located a twentyminute walk from the centre of Hanley. There were local shops and health care services closer to the home. The home provided all single bedrooms with four upstairs and two downstairs. The home had a bathroom and separate toilet upstairs and a shower room with toilet downstairs. The standard of the home would be improved if the upstairs bathroom was upgraded and redecorated. The home was decorated and furnished throughout in a domestic style. Externally the home had a small front garden and a rear yard with table and Poplars DS0000064016.V303572.R01.S.doc Version 5.2 Page 20 chairs for sitting out. The rear yard was uneven and at the present time was a hazard to residents and staff. Residents said they liked their bedrooms and that they were lockable. Bedrooms were of varying size some being of an adequate size whilst others were large having double beds. No bedrooms were ensuite but all had a washbasin provided. All bedrooms had suitable storage and were provided with seating. The residents had personalised their rooms with a range of personal possessions including ornaments and pictures. The home had sufficient toilet and bathing facilities. These were all lockable. The home had suitable communal rooms. There was a large lounge with TV and video providing residents with a comfortable place to relax. There was a dining room, which could accommodate all residents to eat together. The kitchen was domestic in style. The home had procedures in place for maintaining the cleanliness and hygiene of the home. The staff worked to daily schedules and toilets and bathing areas were cleaned daily. Residents worked with staff on certain cleaning tasks such as cleaning bedrooms and vacuuming the home. It was noted that some cleaning equipment was being kept in the kitchen near food preparation areas. The home shared a laundry with the two adjoining homes. This had suitable washing and drying machines but the walls of the laundry needed to have a readily cleanable surface. Poplars DS0000064016.V303572.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33, 34,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s staffing levels were adequate to meet the health and personal care needs of the residents but did not provide sufficient time to provide support to residents to undertake many activities. Although staff were aware of residents’ needs and interacted positively, the service for residents would be improved by having a greater number of staff who were suitably qualified. The home’s recruitment and selection procedures were safeguarding the residents. EVIDENCE: The residents said they got on well with the staff saying that they were supportive and approachable. They said that staff listened to them and would sort out any problems they raised. The staff member on duty was fully aware of the residents’ needs and interacted with residents in a positive manner. She was able to use British Sign Language to communicate with one staff member that had sensory needs. A health specialist who had contact with the home reported that the home worked in partnership and that staff demonstrated a clear understanding of residents’ needs. Poplars DS0000064016.V303572.R01.S.doc Version 5.2 Page 22 At the current time the home had one staff that was qualified to at least NVQ level 2. Several other staff were in the process of taking the Learning Disability Framework induction programme. The home had one staff member on duty throughout the day and one staff sleeping at the home overnight. This staff member also had to undertake cleaning and catering duties. This level of staffing was adequate to support the residents to have their health and personal care needs met but did not leave much time to support residents to undertake social and leisure activities. The home’s manager would provide some support for the staff member to take residents for some activities and to attend health care appointments and a staff member from another home provided support for residents to go to college. The home had a suitable recruitment and selection procedure. Prospective staff completed application forms and formal interviews were held. The home sought two references and a satisfactory POVA and CRB check were completed. Staff were made aware of the General Social Care Council Code of Conduct. Staff completed an induction course at college, which provided new staff with basic information about care practices and health and safety issues. The home maintained records of the training staff had received. Poplars DS0000064016.V303572.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents were benefiting from living in a home that was being suitably led. Whilst the home had systems in place for reviewing the service this requires further development to include a plan identifying how the home can improve its service to the residents. The health and safety procedures and practices were safeguarding the residents but protection will be improved when the home has fully implemented the fire action plan. EVIDENCE: The Care Manager had worked at the home for several years. She had the necessary knowledge and skills to be an effective manager. She was close to completing NVQ 4 in care and management. She had undertaken training to maintain her knowledge of current issues. She had the responsibility for ensuring the home met the necessary standards and legislation. Poplars DS0000064016.V303572.R01.S.doc Version 5.2 Page 24 The home had some systems in place to monitor and review the quality of the service provided to the residents. This included a range of monthly audits including health and safety issues, the support plans and residents’ finances. The home also undertook surveys of residents to ascertain their views of the home. Residents’ views were also sought through regular residents meetings. This home did not have a development plan, except in relation to the environment that was aimed at improving the service. The home had Health and Safety procedures in place. The home had programmes in place to ensure that staff were up to date with training in health and safety including moving and handling, fire safety, food hygiene and first aid. Some staff had undertaken comprehensive training in infection control. A sample of service records were examined and these demonstrated that the home was undertaking the necessary servicing. Portable testing was up to date and the fire checks were being completed. Records were being kept of water temperature and some measures were in place to prevent the legionella bacteria. The home had procedure sin place for the safe storage and handling of hazardous products and such products were kept locked away. The home was working towards completing a fire action plan, a result of a recent fire service visit. This required an evacuation plans being completed and specialist equipment for a resident with sensory impairment. Poplars DS0000064016.V303572.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 4 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Poplars DS0000064016.V303572.R01.S.doc Version 5.2 Page 26 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 YA14 YA33 Regulation 18(1)(a) Requirement Timescale for action 26/09/06 2. 2. YA20 YA20 YA23 3. 4. 5. YA24 YA32 YA30 6. 7. YA39 YA42 To ensure that staffing levels allow for the provision of suitable activities both in and out of the home. (Previous timescale of 1/12/05 not met) 13(6) To ensure that accurate medication records are kept at all times. 18(1)(c)(i) To ensure that all staff receive 13(6) appropriate training: i. in medication ii. in adult protection. 23(2)(b)& To ensure that the rear yard is 13(4)(c) repaired and does not present a hazard. 18(1)(a) To demonstrate progress in increasing the number of qualified staff. 16(2)(j) To ensure that suitable practices for the control of infection are in place i.e. i. Suitable storage of kitchen cleaning equipment ii. That the laundry walls are easily cleanable. 24(1)(b) To develop the quality review to include a plan for improvement. 23(4) To ensure that the fire action plan is completed as scheduled. DS0000064016.V303572.R01.S.doc 27/07/06 01/10/06 14/08/06 01/10/06 01/09/06 26/09/06 31/07/06 Poplars Version 5.2 Page 27 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 YA24 YA30 YA35 Good Practice Recommendations To upgrade and decorate the upstairs bathroom. To provide all staff with infection control training To develop a training profile for the home Poplars DS0000064016.V303572.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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