Inspection on 30/11/06 for Poplars

This inspection was carried out on 30th November 2006.

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 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 05/01/06

Poplars 30/08/05

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 Deavanand Ramdas Key Unannounced Inspection 30th November 2006 10:00 Poplars DS0000028508.V316758.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 DS0000028508.V316758.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 DS0000028508.V316758.R01.S.doc Version 5.2 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 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) p.a.winchester@talk21.com Gresham Care Jane Turtle Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Poplars DS0000028508.V316758.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 18 - 45 YEARS 5th January 2006 Date of last inspection Brief Description of the Service: Poplars is registered with the CSCI (Commission for Social Care Inspection) to provide accommodation and care for six service users with a learning disability. The premises are located in Horley, Surrey and close to public amenities and facilities. Accommodation is on two floors accessed by stairs and comprises of an office, two lounges, a kitchen with a dining area, utility room, bathrooms, toilets and six single bedrooms, three of which have en-suite facilities. The home has a garden which is well maintained, secure and accessible. Private parking is available. The range of fees charged by the home is £1,300 to £2,174 per week. The registered manager is Ms. Jane Turtle. Poplars DS0000028508.V316758.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes site visit as part of the key inspection process by the Commission for Social Care Inspection henceforth referred to as the CSCI and carried out by Mr. D. Ramdas. The inspection commenced at 11:30 hrs and finished at 17:00 hrs and included a tour of the premises, interviews with staff and service users, and a review of documents and care records. The inspector noted some service users have communication difficulties and judgements were made about them based of their mood, behaviour and information given by staff. The inspector would like to thank the manager, staff, service users, relatives and professionals for their contribution to the inspection. What the service does well: The home has an experienced registered manager who provides management stability, leadership and direction to the staff team. During discussions a member of staff stated ‘‘the manager leads by example and we work as a team’’ and a visiting professional recorded ‘‘keep up with good communication and openness’’. The complaints process at the home is excellent with complaint information in a widget format (a method of communication using pictures and symbols) to make the information accessible to service users. Further evidence confirmed a complaint about the home was investigated with appropriate action taken and the CSCI notified of the outcome. It is recorded by a relative ‘‘we have not had any cause to raise or concern, but if we did I am sure it would be dealt with professionally and appropriately’’. Activities at the home are well planned and organised with service users supported in valued and fulfilling activities. Further evidence confirmed service users attend local colleges and have work placement including paid and voluntary work. During discussions a service user commented ‘‘I went to College at East Grinstead and for a sponsored walk’’. The home values equal opportunity and diversity and staff have training in diversity awareness. Further evidence confirmed staff have value based training and person centred plans reflected the unique needs of each service user. It is recorded by a relative ‘‘I am very impressed with the way staff spoke to and dealt with service users’’. The home had good arrangements for meeting the health care needs of service users with health action plans to promote and maintain good health. It is recorded by a relative ‘‘I am very impressed with how speedily the home dealt with medical matters’’. The premises are well maintained and comfortable with recent investment to improve the environment for the enjoyment of service users. The lounge has been decorated with new carpets and fabric covers to settees to make it attractive for service users and the hallway and bathroom has been decorated to make it nice for service users. Poplars DS0000028508.V316758.R01.S.doc Version 5.2 Page 6 The home has a dedicated budget for staff training and the company has a contract with an approved provider for NVQ (National Vocational Qualification) training. During discussions a member of staff stated ‘‘training is tailored to the work we do’’ and ‘‘I have NVQ Level 2’’. 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 DS0000028508.V316758.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Poplars DS0000028508.V316758.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes statement of purpose and service user guide is good ensuring prospective service users have up to date information on which to make decisions about admission to the home. The arrangements for assessing needs are good ensuring the aspirations and needs of prospective service users are assessed before admission to the home. EVIDENCE: The home had a statement of purpose and service user guide which was written in plain English, nicely presented and available for information. The inspector noted the manager was aware of the disability of service users and information was in a widget format (a method of communication using pictures and symbols) to make the information understandable to service users. The manager stated prospective service users would be admitted to the home following an assessment of needs. Further evidence confirmed the home had a statement on assessing needs and an initial referral and assessment form for assessing the needs of prospective service users. A review of records confirmed needs assessment covered personal care, health needs and social support which was dated and signed by the manager. The inspector noted there had been no admissions to the home since the last inspection by the CSCI and relatives/visitors comment cards indicated satisfaction with the overall care provided by the home. Poplars DS0000028508.V316758.R01.S.doc Version 5.2 Page 9 Poplars DS0000028508.V316758.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7&9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for care planning are good and reflect the changing needs and personal goals of service users. Decision-making is good safeguarding service users’ right to make decisions with assistance as needed. The systems for risk taking are good promoting the independence of service users. EVIDENCE: The home has person centred plans and care plans which sets out in detail action to be taken by staff with regards to personal care, health needs and social support. Further evidence indicated care plans are reviewed with service users and involving families and other professionals as appropriate. A review of records confirmed care plans are reviewed at least every six months, dated and signed by the manager and service users. The manager remarked the homes key worker system is being reviewed to promote consistency and Poplars DS0000028508.V316758.R01.S.doc Version 5.2 Page 11 continuity of care and during discussions a service user commented ‘‘I like my key worker’’. The home had regular meetings with service users to promote decision making in the home and minutes of meetings were in a widget format (a method of communication using pictures and symbols) to make the information understandable to service users. A review of records confirmed service users had made decisions about holidays and Christmas arrangements at the home which was recorded for action. The inspector noted one service user had a named advocate and attended an advocacy group supported by staff to promote rights and decision-making. The home had a policy on risk taking and staff have risk assessment training. Further evidence confirmed the home had risk assessments and risk management guidelines to promote the independence of service users in activities of daily living including cooking, cleaning, ironing and the use of public transport. A review of records confirmed risk assessments were reviewed, updated and signed by staff and service users to promote personal safety. Poplars DS0000028508.V316758.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16&17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for education and occupation are excellent ensuring service users participate in valued and fulfilling activities. Community links and social inclusion are good ensuring service users are part of the local community. The systems for relationships are good and promote family links and friendships. Daily routine at the home is good and promote the independence of service users. Meals at the home are good and offer variety and choice. EVIDENCE: The home supported service users in valued and fulfilling activities and each service user had a weekly activity programme. Further evidence indicated service users attended local colleges and had work placements and the company employed a placement officer to find opportunities for paid and Poplars DS0000028508.V316758.R01.S.doc Version 5.2 Page 13 volunteer jobs. A review of records confirmed one service user had paid employment at a local supermarket and another service user will be attending an interview for a volunteer job with Age Concern to promote employment skills. It is recorded by a relative ‘‘activities are available in the home but my son decides not to participate’’ and during discussions a service user commented ‘‘I went to college at East Grinstead and for a sponsored walk’’. The home promotes community links with service users accessing the local community and facilities including, shops, pubs, leisure centres and cinema. During discussions a service user commented ‘‘I went to the cinema to watch James Bond with staff’’. Further evidence confirmed the home had it’s own transport to promote community access and a review of records indicated a complaint made by a neighbour was investigated with appropriate action taken to maintain good neighbourly relationships with the community. The home had a visitor’s policy and the manager stated family and friends are welcomed at the home. A review of records confirmed relatives visited the home and during discussions a service user commented ‘‘I go home to see my mum’’. The manager commented the home had a daily routine to promote independence and observations confirmed staff knocked on doors before entering bedrooms and bathrooms. Further evidence indicated one service user had a key to the front door to promote independence and service users had unrestricted access to the home and grounds. The home had written menu plans and service users participated in planning the menu and cooking meals. The inspector noted the home catered for the dietary needs of service users and one service user with a medical condition had a low fat and low carbohydrate diet to promote health. A review of records confirmed menu plans reflected variety, choice and healthy eating options. Following discussions with the manager recommendations were made to review menu records at the home and for menu plans to have dietician input to ensure it is adequate to meet the nutritional needs of service users. Poplars DS0000028508.V316758.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19&20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for personal support are good ensuring service users receive personal support in the way they prefer and require. The systems for health care are good ensuring the physical and emotional needs of service users are met. Medication needs strengthening to promote health. EVIDENCE: The home provided flexible personal support and care plans reflected the preferred routines and likes and dislikes of service users. A review of records indicated guidance regarding personal care with risk assessments to support service users to bath independently and promote privacy and dignity. The manager stated service users choose their own clothing with assistance from staff as is necessary and observations confirmed service users had good personal hygiene and were appropriately dressed which indicated flexible personal support. The home had arrangements for meeting the health needs of service users who were registered with a local GP (General Practitioner) and the home had input from a district nurse and community learning disability nurse. Further Poplars DS0000028508.V316758.R01.S.doc Version 5.2 Page 15 evidence indicated the home had health action plans and accessed the local PCT (Primary Care Trust) for health care services. A review of records indicated the district nurse provided staff training to meet the needs of a service user with a medical condition with the GP doing annual health checks to promote the health of service users. It is recorded by a relative ‘‘I am very impressed with the way the home dealt with medical matters’’. The home had a policy on medications, a service level agreement with a local chemist and adequate storage of medications. Further evidence indicated medication record sheets were dated, signed by staff and had a recent photograph of the service user attached for information. A review of records indicated the home had a pharmacy audit and kept a record of medications received by and disposed of by the home to prevent mishandling of medications. The inspector noted the company has a contract with a local chemist to provide staff training in medications and has appointed a named staff to lead on matters pertaining to medications. Observations confirmed handwritten prescriptions on medication record sheets were not dated and signed by staff, homely remedies were not printed on medication record sheets and the home had a surplus stock of medications to be returned to the pharmacy with action required in respect of these matters to promote health. Poplars DS0000028508.V316758.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22&23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaint process is excellent with complaint information available to staff, service users and relatives. The arrangements for protection need strengthening to safeguard the welfare of service users. EVIDENCE: The manager stated the home had a complaints policy and kept a record of complaints at the home for information. The inspector sampled the complaint records and noted one complaint recorded with appropriate management action taken by the home. Further evidence confirmed the complaints policy was in a widget format (a method of communication using pictures and symbols) to make the information understandable to service users and complaint information was included in the service user guide. During discussions a member of staff stated ‘‘when you join the company you have to go through the complaints procedure’’ and a relative recorded ‘‘we have not had any cause to raise or concern, but if we did I am sure it will be dealt with professionally and appropriately. The inspector noted no complaints were recorded about the home since the last inspection by the CSCI. The home had a statement on abuse and a copy of the local authority (Surrey County Council) procedures on safeguarding adults. Further evidence confirmed the home had a whistle blowing policy and a restraint policy and staff have training in restraint to maintain the safety of service users. A review of records indicated management guidelines and risk assessments for dealing with physical and verbal aggression and following discussions with the Poplars DS0000028508.V316758.R01.S.doc Version 5.2 Page 17 manager a requirement has been made for staff to have refresher training in safeguarding adults to protect service users from harm. The inspector noted no safeguarding adult matters were recorded about the home since the last inspection by the CSCI. Poplars DS0000028508.V316758.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24&30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s premises are good promoting a homely and comfortable environment for service users in which to live. The arrangements for hygiene are good ensuring the home is clean and hygienic for staff and service users. EVIDENCE: The home’s premises are suitable for its stated purpose and in keeping with the local community. The home has a good standard of décor with good quality furniture and fittings and is clean, nicely presented and comfortable. Recent investment by the company has significantly improved the environment and the hallway and lounge has been decorated with new carpets to the lounge area, new fabric covers to settees and one bathroom has been decorated for the comfort and enjoyment of service users. Observations confirmed the garden is well maintained and accessible to service users and during discussions a service user commented ‘‘my bedroom is nice’’. The home has a policy on infection control and a service level agreement with an approved contractor for the disposal of clinical waste. Further evidence Poplars DS0000028508.V316758.R01.S.doc Version 5.2 Page 19 indicated the home had adequate laundry facilities with washing machines and a dryer and staff have training in infection control. Observations confirmed hand washing facilities were prominently sited and staff practiced infection control measures by washing their hands regularly to prevent the spread of infection in the home. Poplars DS0000028508.V316758.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34&35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for staff training need strengthening to ensure service users are supported by competent and qualified staff at all times. Recruitment and vetting practices need strengthening to safeguard the welfare of service users. Staff training is good ensuring service users joint needs are met by appropriately trained staff at all times. EVIDENCE: The home is committed to staff training and development with staff having LDAF (Learning Disability Award Framework) training and other relevant and appropriate training including training in autism, challenging behaviour and restraint to safeguard the welfare of service users. Observations confirmed staff were good listeners and during the inspection a service user with communication difficulties was supported in line with care plans and risk assessments. The company has a contract with an approved provider for the provision of NVQ (National Vocational Qualification) training and a review of staff training records confirmed less than fifty percent of staff working at the home have the qualification. Following discussions with the manager a requirement has been made for an action plan to be completed outlining how the home is going meet training requirements in this area to ensure service Poplars DS0000028508.V316758.R01.S.doc Version 5.2 Page 21 users are supported by competent and qualified staff. The home has a policy on recruitment and retention of staff based on equal opportunities. The inspector sampled staff recruitment files which included completed application forms, references, statement of terms and conditions, job descriptions, CRB (Criminal Record Bureau) disclosure information and a recent photograph of the employee. The manager stated staff are recruited to the home in line with the GSCC (General Social Care Council) code of conduct with copies given to staff for information. Following discussions with the manager a requirement has been made for staff application forms to be revised to include at least a ten-year employment history to protect service users from harm. The home has a structured induction programme and the company has a dedicated budget for the provision of staff training and development. Further evidence confirmed training is linked to service users’ needs and staff have development plans including regular appraisal. A review of records confirmed the home had an induction checklist dated and signed by staff and staff have equal opportunities training. During discussions a member of staff stated ‘‘training is tailored to the work we do’’ and ‘‘advice and support is available from other houses’’. Following discussions with the manager a recommendation has been made for induction and foundation training to reflect Skills for Care common induction standards to promote good practice. Poplars DS0000028508.V316758.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39&42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for day to day management are good ensuring service users benefit from a well run home. The systems for quality assurance are good ensuring service users participate in the running of the home. Health and safety practices are good and safeguard the welfare of staff and service users. EVIDENCE: The home has a registered manager with the RMA (Registered Manager Award) qualification. The inspector noted the home had a management structure with clear lines of accountability and communication. During discussions a member of staff stated ‘‘the manager leads by example and we work as a team’’ and a Poplars DS0000028508.V316758.R01.S.doc Version 5.2 Page 23 professional who visited the home remarked ‘‘keep up with good communication and openness’’. The home had a policy on quality assurance and used questionnaires to obtain feedback about the home. The inspector noted a summary report dated March 2006 which included comments from relatives, advocates and other professionals was available in the home for information. Further evidence confirmed the home had regular Regulation 26 (monitoring visits) with appropriate management action taken to safeguard the welfare of service users and staff. A review of records confirmed the home had regular meetings with staff and service users to participate in decision making and running of the home as appropriate and during discussions a member of staff remarked ‘‘we have a great working relationship with good team working’’. The home had a policy on health and safety and staff have training in fire safety, food hygiene, first aid and other appropriate and relevant training. On the day of the inspection a fire safety officer was conducting a fire safety risk assessment of the home to promote safety and a review of records confirmed the home had a visit from the local authority (Surrey County Council) environmental health officer with appropriate action taken by management. Further evidence indicated the home had a current gas safety certificate, electrical wiring certificate and a legionella bacteria test. Observations confirmed the kitchen appeared clean and hygienic, and fridge and freezer temperatures were within normal limits to promote food safety. Poplars DS0000028508.V316758.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 4 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 3 X X 3 X Poplars DS0000028508.V316758.R01.S.doc Version 5.2 Page 25 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 YA20 Regulation 13(2) Requirement The registered person must ensure medication record sheets provided by the chemist include medications which are used as homely remedies to safeguard the welfare of service users. The registered person must ensure surplus medications are returned to the pharmacy to promote health. The registered person must ensure staff have refresher training in safeguarding adults to protect service users from harm. The registered person must ensure the home has an action plan with timescales to determine how the home will meet NVQ training targets to ensure service users are in safe hands at all times. The registered person must ensure staff application forms are revised to include at least a ten-year employment history to protect service users from harm. Timescale for action 01/02/07 2 YA20 13(2) 10/12/06 3 YA23 13(6) 01/04/07 4 YA32 18(1)(a) 01/03/07 5 YA34 7,9,19 Schedule 2 10/01/07 Poplars DS0000028508.V316758.R01.S.doc Version 5.2 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 2 3 Refer to Standard YA17 YA20 YA35 Good Practice Recommendations The registered person should consider ensuring the homes menu plan have input from a dietician to meet the nutritional needs of service users. The registered person shall consider ensuring hand written prescriptions are dated, signed and witnessed by a second member of staff to promote health. The registered person should consider ensuring the homes induction programme reflect Skills for Care common induction standards to promote good practice. Poplars DS0000028508.V316758.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 DS0000028508.V316758.R01.S.doc Version 5.2 Page 28 - 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. 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