Inspection on 30/08/05 for Poplars

This inspection was carried out on 30th August 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Poplars 13/11/08

Poplars 30/11/06

Poplars 05/01/06

Poplars 01/12/04

Poplars 07/09/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Poplars 87 Povey Cross Road Hookwood Surrey RH6 0AG Lead Inspector Mr Devanand Ramdas Unnanounced 30 August 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Poplars Address 87 Povey Cross Road Hookwood Surrey RH6 0AG 01293 825154 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Gresham Care To be confirmed Care Home 6 Category(ies) of LD - Learning disability 18-45 Years (6) registration, with number of places Poplars H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accomodated will be :18-45 YEARS Date of last inspection 1st December 2004 Brief Description of the Service: Poplars is a care home for people with a learning disability. The property is located in Horley, Surrey that is close to public amenities. The nearby villages of Hookwood and Salfords can be accessed but transport is needed to reach towns like Crawley and Redhill. The accommodation is on two floors and comprises of two lounges, a dining rooom, kitchen, utility room, office and adequate washing and bathing facilities. There are six single bedrooms, three on each floor some with en-suite facilties. The home has a large well maintained garden to the rear of the property and private parking is available. The home is owned and managed by Gresham Care and the manager is Mrs. Jackie Turtle. Poplars H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector over five hours. The manager of the home was on annual leave and the deputy manager facilitated the inspection. The inspector noted some service users at the home had communication difficulties. A full tour of the premises took place and staff, service users and a relative were spoken to. Documents and care records were checked. The inspector would like to thank the deputy manager, placement officer, staff and service users for their contribution to the inspection. Feedback forms, comment cards and CSCI business cards were left at the home. What the service does well: What has improved since the last inspection? What they could do better: Policies and procedures must be improved. The home must update the complaint policy to ensure the process for making a complaint is clear and the Vulnerable Adults policy to ensure staff have up to date information to protect service users from harm or abuse. The environment must be improved. The flooring in the bathroom must be replaced and ventilation in the office must be improved for the comfort of staff and service users. An application for registration as manager must be submitted to the Commission without delay. Poplars H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 6 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 H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Poplars H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 8 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 standard(s) 1,2,5 The homes Statement of Purpose and Service User Guide are good providing service users and prospective service users with the details of the services the home provides enabling an informed choice to be made about admission to the home. The arrangement for assessment is adequate ensuring service users needs are assessed and identified. Contracts are offered by the home to ensure service users tenancy rights are protected. EVIDENCE: The home had a Statement of Purpose and Service User Guides. The Statement of Purpose was kept in a folder in the office and contained information about the provider, staffing, staff training, client charter of rights, care plan reviews, service user agreements, complaints and admissions policy. The inspector noted the Statement of Purpose was updated in July 2005. Service users kept their service user guides in their bedrooms. The inspector noted the information it contained was written in plain English and also available in a widget format. The inspector noted the complaint process needed updating to reflect a complaint could be made to the commission at any stage. This was discussed with the deputy manager. The home had an Admission Placement policy dated August 2005. The inspector noted service users had individual person centred plans that covered personal, social and health care needs. The deputy manager stated person centred plans were introduced in July 2005. The home offered contracts to service users that were in the service user guides. The inspector noted contracts were in a widget format and signed by the manager and service user. Poplars H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 9 Poplars H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 10 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 standard(s) 6,7,8,10 There is a care planning system in place to adequately provide staff with the information they need to satisfactorily meet service users’ needs. The arrangements at the home ensure service users are supported to make decisions about their lives. The systems at the home ensure service users are consulted and participate in the running of the home. The systems at the home are adequate ensuring information on service users is securely and confidentially stored. EVIDENCE: The home had Person Centred and Health Action Plans dated May 2005. The inspector sampled the plans and noted the assessments reflected the service users personal goals. The plan of one service user described what she liked and disliked, what she enjoyed and preferred and what was important to her. One service user who is likely to be aggressive had a care plan on being healthy and safe and a health action plan on self harm and bruising. The inspector noted the home had a policy on Aggressive Behaviour Towards Staff dated August 2005. The home supported service users to make decisions about their lives. One service user with communication difficulties had input from a speech therapist to enable her to communicate her needs and to participate in her person centred plans. It is recorded the service user liked listening to music, shopping, swimming and food, she disliked being stuck in traffic, changes to her routine, walking and eating plums. The home has Poplars H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 11 regular ‘Client Meetings’. The inspector sampled the minutes of meetings and noted the last meeting was held on the 27th June 2005 at a local pub. It is recorded one service user wanted to go to the cinema to see Charlie and the Chocolate Factory and another wanted to go to Chessington World of Adventures. Minutes of meetings were in a widget format and displayed on a notice board for information. The home has policies on Confidentiality and Access to Files dated August 2005. The inspector noted service users files were kept in a locked cupboard in the office. Poplars H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 12 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 standard(s) 12,13,14,15 Links with the community are good and support and enrich service users’ social, leisure and educational opportunities. The arrangements at the home ensure service users are supported to maintain positive relationships. EVIDENCE: The home had activity plans. The inspector noted service users attended a local college supported by staff. One service user stated he worked at a local supermarket for which he was paid a minimum wage and remarked he has made many new friends at work. At college service users were taught money skills, arts, crafts and health studies. The deputy manager stated the home had good neighbourly relationships with the community. The inspector noted service users were involved in a project recycling paper and tins. One service user stated he was a member of Dorking Library and had a membership card. Service users went line dancing, trampolining and had trips out to the seaside and local parks. The inspector noted a two centre holiday was planned for service users on 12th September 2005. The home had a computer that had internet access. The deputy manager stated two service users used the internet to maintain contact with their families. During the inspection the Poplars H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 13 inspector noted a relative was in the home attending a care plan review meeting. Poplars H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 14 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 standard(s) 18,19 Personal support was offered in such a way as to maximise service users dignity and independence. The health needs of service users are met with evidence of working with other health care professionals taking place on a regular basis. EVIDENCE: The home had a key worker system. The inspector noted a key worker was booked to attend makaton training to support a service user who had communication difficulties. On the day of the inspection service users were appropriately dressed. One service user was dressed in shorts and a tee shirt because of the hot weather. The deputy manager stated a female service user went to a ‘make up’ party and buys her own make up. The inspector noted the service user had ‘make up’ in her bedroom and her personal appearance was good. Staff addressed service users by their preferred names and the deputy manager was observed to knock on bedroom doors before entering service users rooms. The deputy manager stated service users were registered with a local GP and used the special needs dental service at East Surrey Hospital. The inspector noted advice was sought from the GP on the use of contraception for female service users and service users had regular health checks. One service user attended the Well Person Clinic on the 20.10.04, the dentist on the 20.7.05, and had a follow up from the district nurse on the 8.7.05. Poplars H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 15 Poplars H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 16 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 standard(s) 22,23 The complaint process in this home is satisfactory with complaints information available to service users, staff and relatives however, the complaint procedure must be improved to ensure the process for making a complaint is clear. Arrangements for protecting service users are satisfactory however, the vulnerable adults policy must be improved to ensure staff have up to date information to protect service users from harm or abuse. EVIDENCE: The home had a complaint policy dated August 2005. The inspector noted the policy was kept in the office and signed and dated by staff. The policy was in widget format to make it more accessible to service users and was displayed on a notice board for information. The deputy manager stated the home had a complaint folder. The inspector sampled the folder and noted no complaints were recorded. The home had a policy on Vulnerable Adults and Whistle blowing dated August 2005. The inspector noted the home had the local authority (Surrey County Council) multi-agency procedures on the protection of vulnerable adults dated February 2005. The inspector noted staff had training in responding and managing aggression and the home had a policy on managing aggressive behaviour towards staff dated August 2005. During a meeting staff stated they were aware of the complaint procedure that was reflected in the induction checklist. One service user stated ‘if he had a problem he would speak to the staff and the manager’. The inspector noted the complaint procedure was in need of updating to reflect a complaint could be made to the commission at any stage should a complainant wish to do so as previously stated in this report and the Vulnerable Adults policy must be updated to reflect the category of professional abuse. This was discussed with the deputy manager and action has been required in respect of this matter. Poplars H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 17 Poplars H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 18 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 standard(s) 24,25,26,27,28,30 The standard of the environment within this home is good providing service users with an attractive and homely place to live. However, the flooring in the bathroom must be replaced and ventilation in the office must be improved for the comfort of staff and service users. EVIDENCE: The home had a good standard of décor and furnishings and fittings were of good quality. On the day of the inspection the home was clean and free from offensive odours. Bedrooms were well presented and personalised with family photographs, pictures, ornaments, television, CD player, plants and other items of personal interest. The inspector noted one service user had artwork from college displayed in her bedroom, she remarked ‘I like sleeping in my bedroom, it’s nice’. Some bedrooms had en-suite facilities. The home had adequate bathing and washing facilities and the inspector noted toilets and bathrooms were lockable. The flooring in the downstairs bathroom was marked and stained and in need of replacing. This was discussed with the deputy manager and action has been required in respect of this matter. The home had a large garden that was well maintained, safe and easily accessible. The inspector noted the placement officer supporting a service user to play games Poplars H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 19 in the garden. The kitchen and laundry facilities were adequate. The home had a policy on Infection Control dated August 2005. The inspector noted antibacterial hand wash was widely available and staff and service users washed their hands regularly. During the inspection staff stated the office area was hot and uncomfortable to work in. The inspector noted ventilation was inadequate. This was discussed with the deputy manager and action has been required in respect of this matter. One service user stated ‘I like living here, it’s the nicest home’. She remarked, I could go in the garden, go on the swings and water the tomato plants. Poplars H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,36 The arrangements at the home for staffing are satisfactory ensuring there is sufficient numbers of staff with the right skills to adequately support service users. The arrangements for supervision are adequate ensuring staff are well supported to do their job. EVIDENCE: The deputy manager staff have completed the Learning Disability Award Framework. The inspector noted the manager, deputy manager and the placement officer had completed the NVQ care award. One staff stated, the company offered good training opportunities. During the inspection it was noted service users constantly approached staff for support. One service user that was diabetic was supported by staff to go to her bedroom where she could rest as part of her management. On the day of the inspection the staffing level was adequate. On duty were the deputy manager, the placement officer and a care staff to support five service users. The inspector noted one service user was on leave with her family. The inspector sampled the duty roster and noted it reflected the staff on duty. The home had low sickness levels and did not use agency staff. The deputy manager stated the home had regular staff team meetings. The inspector sampled the minutes of meetings and noted the last meeting was held on the 4th August 2005 and signed and dated by staff. The deputy manager stated staff had regular supervision. The inspector noted the home had a policy on Appraisal Development Plan dated August 2005. During Poplars H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 21 a meeting staff stated they had regular supervision. The home used a diary and daily log system to plan and arrange staff supervision. One staff had an appraisal on the 17.2.05 that was noted in the diary. Supervision records were stored securely in a locked cabinet. Poplars H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 22 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38,40,41. The arrangement for the management of the home is satisfactory with evidence that staff and service users have an input in the running of the home. The policies, procedures and record keeping at the home are adequate ensuring service users’ rights and interests are safeguarded. EVIDENCE: The inspector noted the manager was on annual leave during the inspection and a requirement is being made for an application for registration as manager to be submitted to the Commission without delay. The deputy manager stated the management of the home is good. During an interview staff stated the management is open. One staff stated ‘you can make a suggestion or a contribution to keep the business going’. A service user remarked ‘ I like living here, I like being with other people’. Service users had an input in the running of the home by raising issues about the home at the monthly ‘Client Meetings’. The inspector noted the general manager was on the premises to provide additional support to the deputy manager during a care plan review. Service user records sampled were up to date and accurate and stored confidentially and securely in a locked cupboard in the office. The home had a range of policies and procedures some of which were translated in a widget format to Poplars H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 23 make it accessible for service users. Policies were kept in a folder in the office and at the time of the inspection some policies were being reviewed and updated. The inspector noted policies were signed and dated by staff. A relative stated ‘ I have no problems with the home, I think they are brilliant and doing a good job’. Poplars H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 24 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x 3 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 x 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score x 3 3 x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Poplars Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x 3 x 3 3 x x H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 25 No 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 YA37 Regulation 9 Requirement An application for registration as manager must be submitted to the Commission as soon as possible. The registered person must ensure that the complaint procedure is updated to reflect a complaint could be made to the Commission at any stage should the complainant wish to do so. The registered person must ensure the floor covering in the bathroom is replaced to prevent the spread of infection. The registered person must ensure adequate ventilation is provided in the staff office in particular during periods of hot weather. The registered person must ensure the company policy on Vulnerable Adults is updated to reflect the category of professional abuse. Timescale for action 01.12.05 2. YA22 22(1) 01.10.05 3. YA42 13(4)(a) (c) 23(2)(p) 01.12.05 4. YA24 01.12.05 5. YA23 13(6) 01.12.05 Poplars H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 26 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 Good Practice Recommendations No recommendations were made during this inspection. Poplars H09-H58 s28508 Poplars v233904 300805 stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 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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