CARE HOME ADULTS 18-65
Poplars 123 Regent Road Hanley Stoke on trent Staffordshire ST1 3BL Lead Inspector
Sue Jordan Key Unannounced Inspection 4th July 2007 10:00 Poplars DS0000064016.V342777.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.V342777.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.V342777.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 stoke.enquiry@caretech-uk.com 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), Learning disability over registration, with number 65 years of age (1), Mental disorder, excluding of places learning disability or dementia (6) Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. We are covered by MD but need to able to accept a person with a mental illness who is over 65. 26th July 2006 Date of last inspection 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 close proximity to similar care homes owned by the same company. The Poplars provides a service to six 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 the care manager, Tracey Baddeley. 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 people using the service access a range of college courses and undertake social activities and holidays. The six homes in the area have the use of two people carriers and the people using the service contribute to the running of these vehicles. There is one care staff member on duty at all times and the 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 £333-£463.50. Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours. This was a ‘key inspection’ and the core standards were assessed. The methodologies used were: A day of preparation before the inspection, including scrutiny of the Commission for Social Care Inspection Annual Quality Assurance Assessment completed and returned by the manager. During the visit, the inspector met and spoke to four of the people living in the home and discussions were held with the assistant manager. Observations were made of staff and service user interaction and non-personal care tasks and lunch was taken with some of the people living in the home. The medication systems were checked and a walk round the home taken. Two residents’ care records were checked and staff training records. The service users financial records were also checked. A random selection of the Health and Safety and maintenance records were examined. The last Key Inspection was in July 2006. A Random Inspection to check compliance was carried out in December 2006. Eight requirements and ten recommendations have been made as a result of this inspection. What the service does well:
Regular meetings are held with the people using the service both as a group and individual sessions. They discuss a variety of relevant topics, for example the new complaints procedure and fire safety. Professional assessments are carried out on all prospective residents. These are received by the Home prior to making a decision so that they can be sure they can meet the person’s needs. Care plans and risk assessments are developed for all of the people using the service, which are regularly reviewed. The people using the service are encouraged to be as independent as possible. Each has their own building society account and they can access them
Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 6 independently. Most of the residents are able to use the local bus service and all have a bus pass. The people using the service also have access to two seven-seater people carriers. The financial arrangements for the people using the service are safe and robust. Generally the people using the service are able to choose how they spend their day. Some go to college, whilst others prefer to stay at home. Each person has their own bedroom and they are encouraged to personalise them. Keys to the house and bedroom are available if people choose to have them. Health needs are closely monitored and the people using the service are supported to access the appropriate health professionals. There have been no complaints made about the service at Poplars, either to the Home or the Commission for Social Care Inspection. Staff recruitment procedures are robust and protect the people using the service. Protection of Vulnerable Adults and Criminal Records Bureau checks are carried out for all prospective staff members. Staff receive regular supervision and team meetings are held monthly. Regular mandatory training is provided. What has improved since the last inspection?
The manager has obtained the National Vocational Qualification 4 and Registered Managers Award. The medication procedures have improved. Staff are receiving training and the records are well maintained. A new cabinet has been obtained. The complaints procedure has been developed in pictorial format to help the people using the service better understand it. The organisation has recently introduced the Person Centred Plan approach to care planning, which should ensure individual needs and wishes are established and addressed. Additional activities have been introduced into the Home, particularly for those not wanting to attend college. Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 7 The organisation is setting up a service user forum, which it is hoped one of the people living at Poplars will join. The manager and assistant manager have recently been trained to deliver courses in the Protection of Vulnerable Adults. The assistant manager is also a Learning Disability Awards Framework assessor. Some improvements have been made to the environment including, redecoration of the lounge and two bathrooms, the purchase of new lounge and dining room furniture and the replacement of the bathroom suite. One bedroom has been redecorated and the laundry room walls have been painted and a new sink fitted. Staff have recently had infection control training. The number of staff with appropriate National Vocational Qualifications has increased. Since the last Key Inspection the fire safety officer has visited Poplars and made a number of requirements. The Commission for Social Care Inspection found that these had been addressed during a Random Inspection in December 2006. Caretech had developed and implemented an auditing system and two audits took place at Poplars in 2006. However there have been none in 2007. What they could do better:
More work is required to ensure that the Home is able meet complex and diverse needs, which includes staff training, more comprehensive care planning and information that the people using the service can easily understand. The manager must ensure that all items not included in the cost of fees are clearly listed in the contracts and Service Users Guide. This will ensure that the people using the service have the correct information about what they may be expected to pay. Staff must be trained in the Protection of Vulnerable Adults. The manager needs to obtain the new Local Authority Safeguarding Adults policy and management plans and training in the management of challenging behaviour are needed. The rear yard must be repaired so that it does not present a hazard. The Home should be kept at an equitable temperature throughout to ensure that the people using the service are kept warm. Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 8 The organisation must demonstrate that they regularly review the staffing levels to reflect the needs of the people using the service. There is only one member of staff on duty, which means that individual or impromptu excursions are difficult to facilitate. The manager must ensure that staff training is applicable to the needs of the people using the service so that they can fully support them with their specific needs. The organisation needs to formalise their Quality Assurance arrangements to ensure that the views of people using the service, staff and stakeholders are gathered, the results collated and a report as to any action required available. The Statement of Purpose and Service Users Guide should be developed in formats, which can be understood by the people using the service, to ensure that they have access to the information they may need. It is recommended that the care plans be expanded to ensure that all complex and diverse needs are fully explained and information available to staff as to the individual support required. More work is required to ensure that care planning is based on individual needs, wishes and aspirations. The Person Centred Plan process should assist in this. Consideration should be given as to how the people using the service can be further enabled and supported to be involved in making decisions and informed choices. Up to date the people using the service have been very reluctant to discuss death and any after death wishes they may have. The organisation has commited to continue working in this area, to ensure that individual wishes are known and followed at this very difficult time. Work is still required to improve the environment and the management need to consider redecoration and refurbishment of the Home as outlined in this report, to ensure that the people using the service live in more pleasant surroundings. Systems should be in place to control the risk of infection and consideration given to providing paper towels in the communal bathrooms, toilets, kitchen and laundry and washable flooring in the bathrooms and toilets. A malodour problem needs to be addressed properly. The office and kitchen doors should be fitted with closures that are connected to the fire alarm system. This will better enable safe and free passage throughout the Home. Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 9 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 DS0000064016.V342777.R01.S.doc Version 5.2 Page 10 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.V342777.R01.S.doc Version 5.2 Page 11 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, 3, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The needs of people wishing to move into the Home are carefully assessed and information is available to them in a standard format. More work is required to ensure that the Home is able meet complex and diverse needs, which includes training, more comprehensive care planning and information that the people using the service can easily understand. EVIDENCE: The Home’s Statement of Purpose was reviewed and amended at the beginning of 2007. The organisation has plans to develop the Statement of Purpose and Service Users Guide into more accessible formats for the people using the service. This was agreed as being useful to ensure that all of the people using the service are able to understand their rights and responsibilities. However, regular meetings are held with the people using the service where they discuss issues such as the complaints procedure and the running of the Home. The Statement of Purpose lists the services included in the fees and those not covered. However, the manager needs to revisit these lists to ensure that all items are listed. For example, the people using the service pay for their
Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 12 holidays and for the accommodation used by the accompanying staff. This is not listed. This information should also be included in the contracts. Some of the people using the service have purchased their own bedroom furniture. These items are included on the individual’s inventory as their own personal property. Before people are admitted into the Home, their needs are carefully assessed and the Home receives the required information from the referring agencies to ensure that they can meet the person’s needs. The most recent admission was in October 2006. The people using the service have diverse needs, including communication difficulties, physical and mental health issues and behavioural problems. Organisational training is available for the staff in diabetes, mental health awareness and the management of challenging behaviour. However the training records for this staff group indicate that some of this training still needs to be received. One of the people using the service communicates in sign language and the one member of staff able to sign is away from work at present. It is strongly recommended that all staff working with this person are trained in the use of sign language. The Home is presently completing Person Centred Plans for the people using the service, but they are having difficulties with the completion of this particular person’s plan. They have been able to use the services of an interpreter from ‘Deaf Links’ for some hospital visits. A referral has been made to behavioural services for one of the people using the service and the staff are recording any incidents. However more information is needed to guide staff as to how to manage behavioural problems. Care plans are in place for all of the people using the service, but it was felt that more information is required regarding complex needs, for example diabetes, behaviours and issues identified as a risk such as unexplained absences. Many of the organisational and Home’s documentation could be adapted to be more easily understood by the people using the service, including the Statement of Purpose, Service Users Guide, menus and vital procedures. This could include pictures, photographs, symbols or written in a more easy to understand manner. The organisation has recently developed a more ‘user friendly’ complaints procedure and laminated ‘flash’ cards have been made for the person with hearing loss. Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 13 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 adequate. This judgement has been made using available evidence including a visit to this service. The service recognises the right of individuals to take control of their lives and to make their own decisions and choices and they have various ways of trying to encourage participation. This could be improved and expanded with more focus on individual, diverse and complex needs to ensure that all of the people using the service are able to make informed decisions and choices. EVIDENCE: The care records for two of the people using the service were checked. Generally care plans and risk assessments are in place for most aspects of the person’s life and they are regularly reviewed. However it was felt that more information is required regarding complex needs, for example diabetes, behaviours and issues identified as a risk such as unexplained absences. The organisation has just introduced Person Centred Planning. Following the completion of individual plans the people using the service will invite significant
Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 14 people to meet with them to discuss their ideals and wishes and formulate an action plan. This process is proving difficult to complete with the person unable to hear or verbally communicate. During a discussion with one of the people using the service a number of issues were identified, which included being able to be involved in meal preparation, concerns about diet and weight gain, wanting to access the Internet at the library and worries about using the bus. This was fed back to the assistant manager and it was agreed that these issues should be included in the person’s Person Centred Plan and subsequent action/care plans. Five of the people using the service are assisted with their finances, although they are encouraged to maintain their independence as far as is possible. One of the people manages their own monies. All of the people using the service have their own building society accounts and they are able to access these independently. All of their benefits are paid directly into their own personal accounts. Regular meetings are held with the people using the service at which they discuss a variety of topics, including the daily running of the home and procedures such as complaints or fire safety, menus, activities and holidays. Each person using the service has a monthly one to one session with a member of staff, where they can discuss any concerns or just discuss day-today issues. It was evident during this visit that people using the service are, within the limited staffing levels, generally able to choose how to spend their day; three were at college, one went shopping with a member of staff, one went independently, whilst another stayed at home with a jigsaw. The menus are devised with the people using the service prior to the weekly shopping day. Alternatives are available, however one of the people using the service said that she wanted a more ‘healthy’ diet. It was suggested that this be discussed and actioned in the Person Centred Plan process. None of the people living at Poplars have been involved in staff interviews, although the organisation is planning to explore this. The organisation is setting up a service user forum, which it is hoped one of the people living at Poplars will join. The Person Centred Plan process should enable the people using the service to be more involved in decision making. The introduction of ‘user friendly’ documentation and the ability of staff to communicate with all of the people using the service will help them to make more informed choices and decisions. Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 15 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): 11, 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 organisational ethos promotes independence and the right to live in a flexible environment where the residents’ choice of routines are acknowledged and respected. In practice, this works well for some people but the low staffing levels place limitations upon their ability to deliver an individual service. EVIDENCE: Four of the people using the service attend local colleges during the week and another attends an advanced sewing course, for which she has won awards. The people using the service have concessionary bus passes which enable them to use public transport freely in the whole of the Staffordshire area. Most of them are able to use the bus service independently. The people using the service access the local community including Hanley Shopping Centre, local shops, supermarkets, markets and carboots.
Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 16 One person works voluntarily at a local drop-in centre, helping in the kitchen and with some general clearing up in the refreshment area. The organisation has two 7 seater people carriers. All people using the service are on the electoral register and have the opportunity should they so wish, to cast their votes in local and national elections. Nearly all residents have regular contact with their family. Each person using the service has their own bedroom if they wish to spend time alone. One prefers to eat her meals in her room. People are able to get up and go to bed when they wish. The people using the service can have a key to the house or their bedroom. Annual holidays are organised, although these tend to be as a group. This also applies to outings and trips due to low staffing levels. All excursions have to be planned in advance because there is only one member of staff on duty at a time, which limits the possibility of ‘inpromptu’ outings. One of the people using the service said that she does not like to go out with the others and she feels that she has to go out of the house so that an additional staff member does not have to be rostered to support her only. This does not appear to be a problem for the organisation, but reassurance is needed for this particular individual. The same person said that she would appreciate one to one support at times to help her with meal preparation, using the bus and accessing the Internet. On a normal day it is not possible for staff to offer one to one support. This needs to be addressed within the Person Centred Plan process. Recently additional activities have been introduced for those wishing to stay at home, including board games, beauty treatments and crafts. The people using the service are encouraged to particpate in the Home’s domestic tasks, although the main responsibility for this lies on the staff. This also limits the time they are able to spend with the people using the service. Alternatives to the devised menu are available and a diabetic person is catered for. Fresh fruit and vegetables are part of the daily diet. Staff are trained in food and hygiene practices. One of the people using the service said that she wanted a more ‘healthy’ diet and appeared very concerned about putting on weight. She also wants to be involved in some meal preparation, but would prefer to do this without interruption and with the assistance of a staff member. It was suggested that this be discussed and actioned in the Person Centred Plan process. Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 17 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, 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use services have access to healthcare and remedial services and staff assist them to attend appointments and visit local health care services. The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. EVIDENCE: The people living at Poplars do not require ‘hands on’ support with their personal care but some require encouragement and prompting. This is indicated within the care plans. There is ample recorded evidence that the health of people using the service is monitored and the appropriate medical, professional services accessed. All of the people using the service are registered with a general practitioner and are they supported in making appointments and if necessary attending those appointments. All have six monthly medication reviews. Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 18 All of the people using the service are encouraged and supported to attend dental, chiropody and optician appointments for check ups and treatments. Some attend practice nurse appointments for vaccinations and one the diabetes clinic. Some people using the service are supported to attend outpatients specialist appointments including psychiatry, psychology and mental health services. More information is required as to the risks involved with diabetes. The medication systems and procedures were checked. Medication is appropriately stored in a new cabinet and stock control is monitored. Records are kept of all medication brought into the Home or returned to the pharmacist. The administration records are well maintained and no errors or gaps were seen during this inspection. Protocols have been developed for all PRN medication and explanations as to the reason and effects of medication are available for staff. The staff at Poplars have received ‘in-house’ medication training and their continuing competency will be checked every six months. The manager and assistant manager have undertaken the indepth ‘Safe Handling of Medicines’ course. It is hoped that all staff will receive this training. None of the present people using the service self administer their medication. Up to date the people using the service have been very reluctant to discuss death and any after death wishes they may have. The organisation has commited to continue working in this area, to ensure that individual wishes are known and followed at this very difficult time. Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence including a visit to this service. There have been no complaints about this service and the people using the service have opportunities to express their concerns. The approach to keeping people safe is inconsistent and does not fully protect the residents; some staff have had training around Safeguarding Adults but others have not and there is a lack of information about how difficult behaviours should be managed. EVIDENCE: There have been no complaints made about this service to the organisation or the Commission for Social Care Inspection. A new complaints procedure in pictorial format has been developed and this has been discussed at one of the meetings with the people using the service. The people using the service have opportunity to express their concerns during regular meetings or within their monthly one to one sessions with staff. The Home has access to the Local Authority Adult Protection policy but was asked to obtain the new ‘Safe Guarding’ policies. The organisation undertakes Protection of Vulnerable Adults and Criminal Records Bureau checks on all prospective staff. The financial procedures were checked and the records and monies tallied. The people using the service and the staff member sign all transactions and receipts are obtained.
Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 20 The assistant manager has recently completed training, which will enable her to train staff in the safeguarding of adults. At the time of this inspection this training had not been provided to all of the staff working in the Home, although it was believed that training has been organised. Staff undertaking Learning Disability Awards Framework and National Vocational Qualification training will cover the area of adult abuse. The current support staff at Poplars have not attended training in the management of challenging behaviour and there is a no management plan in place for a person presently experiencing behavioural difficulties. Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 21 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 adequate. This judgement has been made using available evidence including a visit to this service. The home is comfortable but some areas have not been decorated for many years and although there is a programme to improve the decoration, fixtures and fittings, maintenance tends to be reactive rather than proactive. The staff endeavour to keep the Home clean and warm, however this is made difficult by the dated decoration, furnishings and inadequate heating system. EVIDENCE: The Poplars is a large Victorian house, close to Hanley city centre. All of the people using the service have their own bedroom, although none have en-suite facilities. Each has a wash hand basin. The people using the service are encouraged to personalise their rooms, all of which are lockable. There is an upstairs bathroom and separate toilet and a downstairs shower room. A small office/staff ‘sleeping in’ room is provided on the first floor.
Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 22 The people using the service have the use of a communal lounge, a dining room and there is a small ‘domestic’ kitchen. The Poplars share a laundry facility with two adjacent Homes belonging to the same organisation. In the last few months the lounge has been redecorated and new furniture provided. The bathroom suite has been replaced and the bathroom and shower room repainted. A new dining room suite has been purchased. One bedroom has been redecorated and the laundry room walls have been painted and a new sink fitted. Externally the home has a small front garden and a rear yard with table and chairs for sitting out. The rear yard remains uneven and a hazard to residents and staff. Previous requirements to attend to this area have not been complied with. The Home is comfortable and domestic in style but does need redecoration and refurbishment in many areas. Most of the bedrooms, the upstairs toilet, hallway and the dining room are outdated and the decoration ‘jaded’. In places the wallpaper is ripped and the carpets old. Flooring is uneven in a number of areas. The lounge has been pleasantly decorated, spoiled by old curtains, which do not match. The bathrooms although freshly painted require new hygienic flooring. Window coverings are required in the upstairs bathroom. The shower cubicle is small and appears old and flimsy. Both rooms seem cold and bare and do not provide a pleasant environment in which to bathe. The kitchen needs refurbishment. Considering the state of the decoration the staff do a good job in maintaining cleanliness in the Home. However there is a malodour problem, which needs addressing properly. It is also recommended that together with the liquid soap, paper towels are provided in the communal bathrooms, kitchen and laundry to maintain infection control. Staff have recently received infection control training. One of the people using the service said that her bedroom is too cold and the assistant manager confirmed that a problem has been identified. This has been reported and the system needs draining. She said that the organisation is waiting for better weather. The Fire Safety Officer visited the Home in July 2006 and the organisation was required to make a number of improvements. The environmental health officer has not visited the Home recently. The organisation recognises the improvements needed to the environment and have developed an action plan for 2007.
Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 23 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, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people using the service benefit from being supported by staff that are well recruited and supervised. The low staffing levels are adequate for group activities but do not allow for individual or spontaneous pursuits. Not all staff are trained to meet the individual, specific and more complex needs of the people using the service, although courses are available. EVIDENCE: There were two staff on duty during this inspection; the assistant manager and a support worker recently transferred over from another Home. This however is a rare occurrence and there is normally only one member of staff on duty. This has been identified as being a hindrance to the provision of individual excursions and activities. The college is now finished for the summer and this means that six people will need support on a daily basis. The staff member is also expected to undertake all the domestic tasks, including the laundry. The organisation must demonstrate that they regularly review the staffing levels to reflect the service users’ changing needs.
Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 24 Four staff are employed at the home, three of which have National Vocational Qualification 2 or above. The Home does not use agency staff and the staff attend monthly team meetings and receive monthly supervision from the assistant manager. As an organisation, Caretech provides a range of training courses and the staff also attend some arranged by the Local Authority. The training records of the staff employed at Poplars were checked and mandatory training is mainly up to date. However there is a lack of training in the specific needs of the people using the service. For example, diabetes, the management of challenging behaviour and communication. The manager needs to undertake a needsbased training assessment for staff to ensure that they can support the people using the service with their specific needs. The organisation has introduced the Learning Disability Awards Framework award as part of the staff induction and the assistant manager is trained as an assessor. She is also trained to provide training in the Protection of Vulnerable Adults, although as yet she has not delivered any. Three staff files were checked. The organisation obtains Protection of Vulnerable Adults checks before people work in the Home and Criminal Records Bureau checks are also undertaken. Two references are sought and the files contain all of the required elements. Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 25 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 organisation is improving and developing systems that monitor practice and compliance, although more work is needed in this area. The manager is qualified and has the necessary experience to run the Home. Improvements have been made to fire safety arrangements. EVIDENCE: The manager, Tracey Baddeley has recently completed the National Vocational Qualification 4/Registered Managers Award. She is the registered manager of three homes in close proximity. Poplars is managed on a daily basis by the deputy manager, Linda Smith, who has National Vocational Qualification 3 and receives regular training applicable to her role. Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 26 Since the last Key Inspection the fire safety officer has visited Poplars and made a number of requirements. The Commission for Social Care Inspection found that these had been addressed during a Random Inspection in December 2006. Caretech has developed generic risk assessments. The manager has checked them and added additional, specific information if needed. A random selection of the maintenance records were checked, which confirmed that fire safety, electric and gas provision are afforded the appropriate priority. It was suggested that the residents’ names be added to the list of people involved in a fire drill, if applicable. The office door is still being propped open. The assistant manager said that the fire safety officer had agreed this action as long as the office is occupied and that a risk assessment has been completed. The risk assessment was not seen during this inspection, although the door was not propped open when empty. The kitchen door has to be closed because it is a fire door. This inhibits conversation between the staff and the people using the service when meals are being prepared. It is therefore strongly recommended that the office and kitchen door be fitted with closures, which are connected to the fire alarm system. The area manager visits the Home on a monthly basis to monitor the quality of the service provided. The people using the service regularly meet as a group and in one-to-one sessions with the staff. It was not ascertained whether the organisation uses surveys or questionnaires to gather people’s views, which should include service users, staff, families and stakeholders, or if the results of these are formalised in any way. Daily checks are made to check the cleanliness of the Home. Staff receive regular supervision and attend monthly meetings. Caretech had implemented a quality audit system and Poplars had two audits in 2006. They were given a score, which improved at the second visit. There has not been an audit in 2007. The manager completed the Commission for Social Care Inspection Annual Quality Assurance Assessment document prior to the inspection. The organisation is planning to implement a new Quality Assurance system in the next twelve months. There are plans to initiate a forum for the people using the services in Hanley. Poplars have been asked to send a representative. Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 27 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 2 4 X 5 2 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 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 2 3 X 2 X X 3 X Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 28 Yes 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 YA3 Regulation 12, (1, 4b) 18 (1ci) Requirement More work is required to ensure that the Home is able meet complex and diverse needs, which includes training, more comprehensive care planning and information that the people using the service can easily understand. The manager must ensure that all items not included in the cost of fees are clearly listed in the contracts and Service Users Guide. This will ensure that the people using the service have the correct information about what they may be expected to pay. Systems must be in place, which prevent the people using the service from being harmed, suffering abuse or being at risk of harm or abuse. To ensure that the rear yard is repaired and does not present a hazard. (Previous timescales of 14/8/06 and 01/02/07 not met). The Home should be kept at an equitable temperature throughout to ensure that the
DS0000064016.V342777.R01.S.doc Timescale for action 01/09/07 2. YA5 5 (1b) 01/09/07 3. YA23 13 (6) 18 (1ci) 01/09/07 4. YA24 23(2)(b)& 13(4)(c) 01/09/07 5. YA24 23 (2p) 01/09/07 Poplars Version 5.2 Page 29 6. YA33 18 (1a) 16 (2m) 7. YA35 18 (1ci) 12 (1a, b) 12 (4b) 8. YA39 24 people using the service are kept warm. The organisation must 01/09/07 demonstrate that they regularly review the staffing levels to reflect the needs of the people using the service. The manager must ensure that 01/10/07 staff training is applicable to the needs of the people using the service so that they can fully support them with their specific needs. The organisation needs to 01/10/07 formalise their Quality Assurance arrangements to ensure that the views of people using the service, staff and stakeholders are gathered, the results collated and a report as to any action required available. 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 YA1 Good Practice Recommendations The Statement of Purpose and Service Users Guide should be developed in formats, which can be understood by the people using the service, to ensure that they have access to the information they may need. It is recommended that the care plans be expanded to ensure that all complex and diverse needs are fully explained and information available to staff as to the individual support required. More work is required to ensure that care planning is based on individual needs, wishes and aspirations. Consideration should be given as to how the people using the service can be further enabled and supported to be involved in making decisions and informed choices. The people using the service should be offered the
DS0000064016.V342777.R01.S.doc Version 5.2 Page 30 2. YA6 3. 4. 5.
Poplars YA6 YA7 YA14 6. YA21 7. 8. YA24 YA30 9. 10. YA30 YA42 opportunity to enjoy spontaneous, individual activities. To consider the subject of ageing, death and dying and establish individual wishes. This will ensure that the people using the service and/or their families’ wishes are followed in this event. To consider redecoration and refurbishment of the Home as outlined in this report, to ensure that the people using the service live in more pleasant surroundings. Systems should be in place to control the risk of infection, including paper towels in the communal bathrooms, toilets, kitchen and laundry and washable flooring in the bathrooms and toilets. The malodour problem needs to be managed properly and/or an effective cleaning routine implemented. The office and kitchen doors should be fitted with closures that are connected to the fire alarm system. This will better enable safe and free passage throughout the Home. Poplars DS0000064016.V342777.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Birmingham Local Office 1st Floor, Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ 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
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