Inspection on 29/11/05 for Poplars

This inspection was carried out on 29th November 2005.

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 01/12/08

Poplars 11/01/08

Poplars 09/02/07

Poplars 22/07/05

Poplars 18/06/04

Poplars 23/09/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Poplars Poplars 15 Ickenham Road Ruislip Middlesex HA4 7BZ Lead Inspector Ged Durkin Unannounced Inspection 29th November 2005 13:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Poplars DS0000027119.V269472.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Poplars DS0000027119.V269472.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Poplars Address Poplars 15 Ickenham Road Ruislip Middlesex HA4 7BZ 01895 635 284 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Appcourt Limited Trading as: Ms Debra Fairholme Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Poplars DS0000027119.V269472.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home shall not accommodate Severely Mentally Infirm residents Date of last inspection 1st July 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 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 building on the ground floor. The number of service users accomodated has not changed. Poplars DS0000027119.V269472.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over early afternoon and early evening from 1:15 pm to 6:30 pm. The Inspector spoke with a number of service users, one relative, two staff members and the Registered Manager, examined a number of documents and had a tour of the building. What the service does well: 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. Poplars DS0000027119.V269472.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Poplars DS0000027119.V269472.R01.S.doc Version 5.0 Page 7 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 the following standard(s): 3, 4 and 6 Although the home has a full assessment process not all the assessments carried out by the home were completed in a satisfactory manner. EVIDENCE: The Registered Manager informed the Inspector that senior staff together with assessments from other agencies assesses all prospective service users. Two of the three assessments carried out by the home had not been signed or dated. Relatives are invited to the home and are invited to ask any questions about the service. The prospective service user is then invited to the home and stays for a meal. The next part of the admission process sees the service user stay for a month’s trial after which a review is conducted to decide whether or not to make the stay permanent. The home does not offer intermediate care. Poplars DS0000027119.V269472.R01.S.doc Version 5.0 Page 8 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 the following standard(s): 7, 8 and 10. The home uses a satisfactory care plan format that incorporates all areas of daily living. The home appears able to meet all healthcare needs of the service users. Staff in the home have a good understanding of the service user’s support needs and ensure respect is given and privacy upheld in any interactions with service users. EVIDENCE: Three service users care plans were sampled. The care plans cover all the areas of daily living and any additional needs. All had been reviewed within the last 10 months. Some of the risk assessments contained in the care plan had not been dated. The home has a link worker system and there is a daily recording about each service user. The Registered Manager informed the Inspector that the home is able to access all appropriate community support services such as GPs and District Nurses to ensure service user’s health needs are met. Staff monitor general physical health and well being when they are assisting with personal care. The services users and their families also communicate Poplars DS0000027119.V269472.R01.S.doc Version 5.0 Page 9 with staff if there are any health issues. Staff are aware of the importance of skin care and senior staff are informed by them of any changes in service user’s health. The Registered Manager also informed the Inspector that staff are reminded of the importance of maintaining service user’s dignity when assisting with personal care. Service users, spoken with, confirmed there were no issues around the way in which staff treated them. The home has had a recent pharmacist inspection, which highlighted a number of issues. The Registered Manager confirmed that she was in the process of addressing these issues. Poplars DS0000027119.V269472.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 12, 13, 14 and 15. The home offers a reasonably full lifestyle, which match some of the expectations of service users. Contact with family and friends is facilitated by the home. Service users are able to exercise full choice and control over their lives and have a good quality of meals that offer choice and variety. EVIDENCE: Some service users spoken with expressed the view that the home should offer more activities than is the case at the moment. The Registered Manager informed the Inspector that activities are undertaken by care staff most afternoons. The Inspector saw a copy of the home’s weekly activity sheet. The home also has a Christmas programme with appropriate yuletide events planned. On the day of the inspection there was a quiz being conducted by one of the care staff, which a good number of service users were engaging in and enjoying. The home does not have a separate activities co-ordinator. The home encourages all visits from friends and family and has external links to organisations such as Age Concern. Service users confirmed that they are able to have a high degree of choice and control over their daily lives. Service users also expressed their satisfaction with the high quality of meals provided in the home. Poplars DS0000027119.V269472.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 16, 17 and 18. The home has a satisfactory complaints system with evidence that service users feel that their views are being listened to and acted upon. The home ensures that service user’s legal rights are protected. Staff have a satisfactory knowledge of Adult Protection issues, which minimise the chances of service users being placed at possible risk of harm or abuse. EVIDENCE: The Registered Manager is not aware of any current complaints against the home and was able to demonstrate, by reference to previous situations, how she has been able to alleviate concerns and resolve, in a satisfactory manner, minor complaints. Service user’s right to vote is ensured because the Registered Manager puts all service users names on the electoral register. The majority of staff have had training on adult protection. The Registered Manager also informed the Inspector that the home also has a video that highlights different types of abuse, which staff are encouraged to watch. One staff member, when spoken with by the Inspector, was not familiar with the term “Whistle blowing”. Poplars DS0000027119.V269472.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. The standard of the environment within this home is good providing service users with an attractive and homely place to live. EVIDENCE: The home’s design, décor and furnishings are all to a high standard. The home has sufficient specialist equipment that includes specialist baths. Service user’s bedrooms, (which are all en-suite), seen by the Inspector showed a high level of personalisation. One issue was brought to the attention of the Inspector around the banging of bedroom doors when they were closed. The Registered Manager said she would investigate and try and resolve this situation. The home was clean and tidy with no noticeable odours present. Poplars DS0000027119.V269472.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The home has satisfactory staffing levels to ensure that service users are able to have their needs met. Recruitment practice in the home is satisfactory but not all the staff records were complete. Staff receive the necessary ongoing training. EVIDENCE: The Registered Manager confirmed that there are four carers and one senior on duty in the morning, three carers and one senior in the afternoon and two waking night staff. There are also separate cleaning staff in the mornings. Examination of staff rotas confirmed these staff numbers. As highlighted at the previous inspection the issue of managing the laundry in its new external location in the rear garden continues to an issue, particularly in the morning, when there is no specific laundry person, (who comes on duty in the afternoon). The Inspector noted a lot of bags of laundry that had accumulated that had not been able to have begun to be washed. Recruitment was ongoing for staff. Two sets of staff records were examined and neither had an up to date photograph of the individual staff member. Training is now an ongoing feature of this home with staff and senior staff going through differing levels of NVQ training. Planned training identified in the last inspection in July that involved refresher training in moving and handling, fire training, assessors training, and first aid training had taken place. Poplars DS0000027119.V269472.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 The Registered Manager manages the home in an open and accessible manner in the best interests of the service users. There are appropriate financial safeguards in place for service users for whom the home looks after small amounts of cash. Staff do not receive detailed individualised supervision sessions but rather have annual assessments. In addition, there are only infrequent staff meetings. Health and safety records were, in the main, satisfactory. EVIDENCE: The Registered Manager informed the Inspector that she tries to ensure that she makes herself available to those who want to see her. This approach was confirmed by the relative and service users that the Inspector spoke to during the inspection. The Inspector examined three service user financial records, which tallied with the amount of money held by the home on their behalf. Staff do not receive supervision along line management lines but rather the Poplars DS0000027119.V269472.R01.S.doc Version 5.0 Page 15 Registered Manager gives all staff yearly assessments. In addition, there are only 2-3 staff meetings a year in which staff have opportunities to discuss issues and share information. The majority of health and safety records examined were in order but the home does not record water temperatures to ensure that the temperature of water is safely maintained. Poplars DS0000027119.V269472.R01.S.doc Version 5.0 Page 16 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 2 3 x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 2 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 2 x 2 Poplars DS0000027119.V269472.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? N0 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. 2. 3. 4. 5. 6. Standard OP3 OP7 OP24OP OP27 OP36 OP38 Regulation 14 (1) Schedule 3 15 (2) (b) 23 (2) (a) 18 Schedule 2 1, 18 (2) 13 (4) (c) Requirement Assessments undertaken by staff must be signed and dated. Service user risk assessments must show evidence of review. Service user bedrooms must be able to be closed without unnecessary noise. All staff records must include a recent photograph. All staff must be appropriately supervised. Water temperatures must be recorded on a regular basis. Timescale for action 16/01/06 16/01/06 16/01/05 16/01/06 30/01/06 23/01/06 Poplars DS0000027119.V269472.R01.S.doc Version 5.0 Page 18 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 OP7 OP12 OP27 Good Practice Recommendations Contents of care plans should be organised to ensure clarity of content. The home should consider employing an activities organiser. The management of the launderette should be monitored. Poplars DS0000027119.V269472.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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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