Inspection on 05/01/06 for Poplars

This inspection was carried out on 5th January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Poplars 13/11/08

Poplars 30/11/06

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 Announced Inspection 5th January 2006 10:00 Poplars DS0000028508.V270043.R01.S.doc Version 5.0 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.V270043.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V270043.R01.S.doc Version 5.0 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 To be confirmed Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Poplars DS0000028508.V270043.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 18 - 45 YEARS 30th August 2005 Date of last inspection 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. Jane Turtle. Poplars DS0000028508.V270043.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out by one inspector over a period of 5 hours. A full tour of the premises took place, staff, service users and a relative were spoken to. The inspector noted some service users had communication difficulties and judgements were made about them based on their mood and behaviour. Policies and procedures, care records and other documents were examined during the inspection and a CSCI business card and leaflets were left at the home for information. The inspector would like to thank the manager, placement officer, staff, service users and a relative for their contributions to the inspection. What the service does well: What has improved since the last inspection? What they could do better: Poplars DS0000028508.V270043.R01.S.doc Version 5.0 Page 6 The home needs to improve care plans by having a section which describe the service users wishes concerning ageing, illness and death which is regularly reviewed with family, friends and other staff as appropriate. Staff training must be reviewed to identify progress towards staff achieving the national vocational qualification (NVQ) in care to safeguard the quality of care given to service users. The company needs to make available a copy of the up to date business and financial plan to assess the financial viability of the home and to protect the interests of service users. 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 DS0000028508.V270043.R01.S.doc Version 5.0 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.V270043.R01.S.doc Version 5.0 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 the following standard(s): 1,3&4 The homes Statement of Purpose and Service User Guide are good providing service users and prospective service users with details of the services the home provides enabling an informed choice to be made about admission to the home. The assessment process is adequate and service users know the home will meet their needs and aspirations. The arrangements for admission of service users to the home is satisfactory ensuring service users have the opportunity to visit and “test drive” the home. EVIDENCE: The home had a statement of purpose and service user guide setting out the aims, objectives and philosophy of the home. The information was clearly written, well presented and in a widget format to make the information accessible to service users. The inspector noted service users had copies of the service user guide in their bedrooms for information. The home has a referral procedure which is used to assess service users and cover areas of self-help skills, self-care, social skills and behavioural problems. Information gathered during assessment is used to identify the needs of service users which is reflected in service users person centred plans. The inspector noted care plans reflected specialist input from a speech and language therapist, a specialist in challenging behaviour and a specialist diabetic nurse. Staff working at the home had completed the learning disability award framework (LDAF) to enable them to meet the needs of Poplars DS0000028508.V270043.R01.S.doc Version 5.0 Page 9 service users. It was recorded in the minutes of an annual review a service users stated “ she is very happy and the Poplars is a good place”. The home has an admission and placement policy which sets out the procedure for admission to the home and includes the opportunity for service users and relatives to visit the home, have a meal, and meet with staff and service users. The inspector noted one service user admitted to the home had a transitional plan and the home offered service users a trial period of three months. Poplars DS0000028508.V270043.R01.S.doc Version 5.0 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 the following standard(s): 9 The systems for risk taking are adequate ensuring service users are supported to take risks as part of an independent lifestyle. EVIDENCE: The home had a risk taking policy dated August 2005 which was signed and dated by staff to indicate they had read the policy. The manager stated the home had general risk assessments to cover the premises and individual risk assessments for service users which were sampled. The inspector noted risk assessments were up to date and signed and dated by the manager, staff and a service user. During a meeting a staff stated “risk assessments were regularly reviewed and updated by key workers”. Poplars DS0000028508.V270043.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,16&17 The arrangements at the home ensure service users have opportunities for personal development. The policies for privacy and dignity are adequate ensuring service users rights are respected in their daily lives. The meals at the home are good and cater for the special dietary needs of service users. EVIDENCE: The manager stated the home provided service users with opportunities for personal development and stated the home employed a placement officer and a college liaison officer to support service users in work and at college. The inspector noted one service user worked as a volunteer in a local playgroup and another had paid employment in a local supermarket. The placement officer remarked “these are my biggest successes” which has resulted in an increase in the service users confidence, communication skills and social skills. The manager stated the home had a policy on dignity and privacy dated August 2005 and one service user had a key allowing him unrestricted access to the home. The inspector noted staff addressed service users by their preferred names and the manager knocking on doors before entering service users bedrooms. The home had a policy on diet and culture dated August Poplars DS0000028508.V270043.R01.S.doc Version 5.0 Page 12 2005 and the manager stated the home had a weekly menu plan and service users participated in menu planning. The inspector sampled menu plans and noted they reflected variety, choice and took account of the special dietary needs of service users with medical problems. The inspector noted one service user was supported to prepare evening meals and during a meeting a staff stated “ I think the quality of the food is good, there is quite a variety and good choice”. Poplars DS0000028508.V270043.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20&21 The management of medication is satisfactory and promotes the health of service users. The arrangements for handling the ageing, illness and death of a service user needs to improve to ensure the illness and death of a service user are handled with respect as the individual would wish. EVIDENCE: The home had policy statements on medications and a service level agreement with a local chemist. The inspector noted medications were appropriately stored in a locked cabinet secured to the wall and regular medications were in blister packs. The home had a small refrigerator to store insulin and the temperature of the refrigerator was within normal limits. Medication record sheets had a recent photograph of service users attached and were dated and signed by staff. The manager stated staff had training in medications and training records were sampled which reflected medication management training and intermediate certificate in the safe handling of medications. The deputy manager was nominated as the lead staff in managing medications and the home had an audit by a pharmacist on the 5/10/05 and recommendations made were acted upon. Homely remedies were available at the home and approved by the GP and a list of names of staff with specimen signatures was available in the medication folder for auditing. The home had a bereavement policy dated August 2005 and the manager stated staff had training in Poplars DS0000028508.V270043.R01.S.doc Version 5.0 Page 14 bereavement. The inspector sampled records and noted staff had training in managing emotion in bereavement, change and loss. The manager commented the provider had sent an information pack on bereavement to relatives which was not responded to and the inspector noted care plans did not reflect the wishes of service users concerning ageing, illness and death. This was discussed with the manager and a requirement has been made in this area to ensure the illness and death of a service user are handled as they would wish. Poplars DS0000028508.V270043.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The complaint process at the home is good ensuring complaint information is available to staff, service users and relatives. EVIDENCE: The home had a complaint policy dated August 2005 which was in a widget format to make the information accessible to service users. The manager stated the home kept a record of complaints and commented no complaint had been made since the last inspection. The inspector sampled the complaint record and noted the last complaint was made in April 2005 and management action was taken. During a meeting a staff stated she was aware of the complaint policy which she covered during her induction training and the inspector noted service users had copies of the complaints policy in the service user guide for information. Poplars DS0000028508.V270043.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26&30 The premises are well maintained ensuring service users live in a homely and comfortable environment. The furniture and fittings provided by the home are adequate ensuring service users bedrooms promotes their independence. The arrangements for hygiene are adequate ensuring the home is clean and hygienic for service users. EVIDENCE: The inspector noted the premises are located in a residential area and in keeping with the local community. On the day of the inspection the home was clean, ventilated and free from offensive odours. The manager stated the home had a renewal programme to replace carpets, decorate service users bedrooms and the inspector noted the furnishings, fittings and equipment were of good quality. Service users had single bedrooms which were well presented and personalised with pictures, paintings, family photographs, radio, television, CD’s and other items of personal interest. The inspector noted one service user who was anxious used her bedroom for comfort and relaxation and another service user stated “I like my bedroom”. Bedrooms had tables, chest of drawers, wardrobes, wash hand basins and adequate bedding, curtains and floor covering and the inspector noted three bedrooms had en-suite facilities. Poplars DS0000028508.V270043.R01.S.doc Version 5.0 Page 17 The manager stated the home had policies and procedures for control of infection and the inspector noted staff had training in infection control. The home had a utility room with washing machines and a dryer, the floor finish was impermeable and easy to clean and laundering facilities were sited away from the kitchen. Observations confirmed staff washed their hands regularly and service users were supported to wash their hands after personal care. During a meeting a staff stated “the hallway and kitchen has been decorated and the home is always nice and clean for service users”. Poplars DS0000028508.V270043.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,34&35 The home has clearly defined job descriptions ensuring staff understand their own and other’s roles and responsibilities. The training of staff needs to improve to ensure service users are supported by staff who have an NVQ qualification. The recruitment and vetting practice are good ensuring service users are protected from harm or abuse. The home have a training and development plan ensuring staff fulfil the aims of the home and meet the needs of service users. EVIDENCE: The manager stated staff were aware of the aims of the home and had job descriptions outlining their role and responsibilities. The inspector noted the home had a management structure and on-call arrangements to provide support to staff who may require advice, support and assistance. All staff were issued with the general social care council (GSCC) code of conduct. During a meeting a staff stated “one of my responsibilities is to be a key worker”. The manager stated the home is committed to training and development of staff and the inspector noted staff had training in communication skills, autism, medications, bereavement and the learning disability award framework (LDAF). The home had professional relationships with the GP, lead diabetic nurse, care managers, speech and language therapist and the specialist support and development team. The inspector noted some staff at the home had the National Vocational Qualification (NVQ) which equated to 33 of the staff Poplars DS0000028508.V270043.R01.S.doc Version 5.0 Page 19 team and a requirement was made for the home to address this shortfall to ensure service users are supported by competent and qualified staff. The home has a policy on recruitment dated August 2005 and the inspector sampled recruitment files which had completed application forms, references, terms and conditions of employment, criminal records bureau disclosure information and a recent photograph of the employee. The home had a staff training plan dated 2006 and the manager stated the company had a dedicated training budget. The inspector noted training was linked to the home’s aims and covered epilepsy, medications, autism, makaton, learning disability award framework and mandatory training including fire, food hygiene, moving and handling and health and safety. The home offered a structured induction training using an induction checklist. During discussions a staff stated “the company provided good training opportunities for staff” and remarked she had enrolled on the NVQ programme. Poplars DS0000028508.V270043.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42&43 The management arrangements at the home are satisfactory ensuring service users benefit from a well run home. The systems for quality assurance are satisfactory ensuring service users participate in the review and development of the home. The home has safe working practices ensuring the health, safety and welfare of service users are protected. The conduct of the home is satisfactory, however information on the business and financial plan of the home must be made available to safeguard the welfare of service users. EVIDENCE: The home has a manager who stated she had day-to-day responsibilities for the management of the home. The inspector noted the manager had a National Vocational Qualification (NVQ) Level 3 and is currently doing the registered managers award (RMA). The manager has submitted an application for registration to the Commission and during a meeting staff stated “the new manager is good, we all work as a team” and commented “the manager discuss things with staff”. The home had a quality assurance system and used Poplars DS0000028508.V270043.R01.S.doc Version 5.0 Page 21 questionnaires to obtain feedback about the home from relatives and professionals. One relative stated “we are pleased with the standards of care and the staff are excellent”. The placement officer stated the home had regular meetings with service users and commented the last meeting was held on the 1/1/06 and attended by six service users. The inspector noted the minutes of the meeting was in widget format, displayed in the hallway for information and contained information about the commission of social care inspection (CSCI) announced inspection of the home. The home met the previous requirements and has an annual development plan dated 2006. The home has a policy on health and safety dated August 2005, a lead staff for health and safety matters in the home and the inspector noted staff have attended a training course in health and safety. The inspector sampled records and noted a gas safety certificate dated 14/12/05, a legionella certificate of analysis dated 8/2/05, electrical wiring certificate dated 21/10/05 and other records which covered fire alarm test and emergency lighting test that was up to date. The home had a certificate of liability insurance due to expire on 31/3/06, systems in place for quality monitoring, supervision of the manager and clear lines of responsibility which is reflected in the management structure of the home. The manager stated the home had an up to date business and financial plan which were kept at the company’s head office and a requirement has been made for a copy of the plan to be sent to the Commission for information to ensure the financial viability of the home. Poplars DS0000028508.V270043.R01.S.doc Version 5.0 Page 22 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 X 3 3 X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 3 X X X 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Poplars Score X X 3 2 Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 2 DS0000028508.V270043.R01.S.doc Version 5.0 Page 23 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 YA - 21 Regulation 12(3) Requirement The registered person must ensure service users care plans have a section to reflect the wishes of service users concerning ageing, illness and death. The registered person must do an action plan outlining how the home will achieve NVQ targets with timescales and a copy of the action plan be sent to the Commission for information. The registered person must ensure a copy of the business and financial plan is sent to the Commission without delay for information. Timescale for action 01/03/06 2 YA - 32 18(1)(a) 20/02/06 3 YA - 42 25(3)(c) 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Poplars DS0000028508.V270043.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. Extracts may not be used or reproduced without the express permission of CSCI Poplars DS0000028508.V270043.R01.S.doc Version 5.0 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!