Inspection on 07/02/06 for Poplars

This inspection was carried out on 7th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Poplars 25/09/07

Poplars 16/10/06

Poplars 10/02/05

Poplars 01/09/04

Poplars 13/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Poplars 63 Naze Park Road Walton On Naze Essex CO14 8LA Lead Inspector Kathryn Moss Unannounced Inspection 7th February 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Poplars Address 63 Naze Park Road Walton On Naze Essex CO14 8LA 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) 01255 675557 01255 676466 Southend Care Limited Victor Zingoni Care Home 37 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (37) of places Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Persons of either sex, aged 65 years and over, who only fall within the category of old age (not to exceed 37 persons) The room registered on 30 May 2003 must not be used by a service user who uses a wheelchair Four service users, aged 65 years and over, who require care by reason of dementia whose names were supplied to the Commission in May 2003 The total number of service users accommodated must not exceed 37 persons The registered provider must review staffing levels (care and ancillary) in consultation with the CSCI within six months of registration, or three months of full occupancy (whichever is the sooner), to ensure that staffing levels are sufficient to meet the needs of the number of residents in the home. 17th August 2005 Date of last inspection Brief Description of the Service: Poplars is a detached, two story property in Walton, Essex, in an attractive location with views over the sea. Since the last inspection, the home has had an increase in the number of registered beds from 29 to 37, incorporating 3 double rooms and 31 single rooms, 15 with ensuite toilets. There are two large lounge/dining rooms on the ground floor, and a smaller lounge on the first floor. The home provides 24 hour personal care and support, and has a through-floor lift and other equipment (e.g. mobile hoist, hand rails, etc.) to assist residents with limited mobility. The home is registered to provide care to frail elderly people, and is not registered to admit people with dementia, although when the NCSC took over regulation of the home in April 2002 there were some existing service users in the home who had dementia. The homes conditions of registration therefore reflect the fact that the home continues to care for these named individuals. The registered provider is Southend Care, and the registered manager is Victor Zingoni. Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 7/2/06, lasting eight hours. The inspection process included: discussions with the manager, 7 staff and 8 residents; the viewing of communal areas; and inspection of a sample of staff and resident records. 12 standards were inspected, and 7 requirements and 8 recommendations have been made. There were 20 people in residence in the home on the day of the inspection, plus two in hospital. Residents spoken to were all positive about the staff team and about the care provided at Poplars. What the service does well: What has improved since the last inspection? Since the last inspection, domestic staffing levels in the home had significantly improved, enabling an appropriate level of domestic support within the home. Residents spoken to felt that the domestic staff were hard working and reported that they kept the home and their individual bedrooms clean and tidy. Although needing ongoing development, the manager had implemented some meetings with staff since the last inspection, as part of initiatives to improve communication processes within the home. The home was also continuing to develop areas of responsibility for senior staff, and had provided opportunity for senior staff to visit other Southend Care homes to broaden their experience. This was a positive initiative, enabling senior staff to learn from the care and management practices in operation in other homes. Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were inspected on this occasion. EVIDENCE: Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9 Residents’ personal care needs appeared to be well met at the time of this inspection, but documentation (care plans) did not satisfactorily describe the assistance required by staff to meet key care needs. Some aspects of medication practices were not satisfactory, and required further action to ensure residents’ health and welfare is protected. EVIDENCE: The care plan for one resident was reviewed with the manager, and contained an appropriate range of care plans, recorded on pre-printed care plan formats relating to different needs. It was good to see care plans covering some specific short-term needs. However, there were no care plans to address two key personal care needs (toileting and continence), and some care plans contained only quite brief information relating to the individual need and the action required by staff to meet the need. For example, a care plan for ‘inability to carry out personal care’ just stated ‘assist with bath’, with no details of the level of assistance required, what the resident could do for themselves, or any information on what help they required with washing. The same was the case for ‘assistance with dressing’, although some good Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 10 information had been included in review notes and other pertinent comments had been included on a separate blank care plan form. There was evidence of care plans being regularly reviewed, with some good review notes detailing changes in the person’s health or abilities. However, where review notes indicated that needs had changed significantly, the relevant care plan and/or risk assessment had not been changed to reflect the different action required of staff. For example, a risk assessment for ‘poor mobility’ still stated that the person could walk short distances by themselves with aid, whereas review notes on a ‘risk of falls’ care plan showed that the person had not been walking independently since December 2005. Care plans had been identified as unsatisfactory over the last two inspections, and remain an issue requiring further action. Some of the issues identified above may reflect the fact that many of the standard pre-printed care plan formats contained little free space for staff to record issues relevant to the individual person. The manager stated that the provider was in the process of conducting a review of care plan documentation. The home’s medication policy was not viewed on this occasion; storage and recording practices were inspected and highlighted some areas for further action. Medication was securely stored, and trolleys containing current medication in use were orderly and clean. The instructions on two open bottles of eye drops stored in the medication trolley stated that the drops should be stored in a fridge once opened; both these bottles of eye drops also appeared to be beyond the timespan in which they should have been discarded from opening. Medication administration records (MAR) showed medication received by the home, and also medication administered. These were generally well completed, although some recording of ‘as required’ medication was inconsistent (i.e. some staff left a gap whilst others entered a code for ‘refusal’). In one instance medication details entered by hand did not show the dose and frequency of the medication, and one medication was being recorded for a second month on the same MAR sheet, but the dates were not clear. There was an unlabelled dropper bottle of olive oil in the medication trolley, and this needed to be clearly labelled as to the content and to whom it belonged. Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 and 15 Practices and routines within the home generally supported residents to exercise control over their lives; however, staff needed to actively promote choices in relation to afternoon bathing routines. Residents received an appealing and balanced diet in pleasing surroundings. EVIDENCE: Lunch was observed being served: this looked and smelt appetising, and residents reported that they were enjoying it. The cook demonstrated a good understanding of residents’ needs, a commitment to producing nutritious meals, and flexibility in planning menus to meet the needs and likes of Poplars’ residents, both individually and as a group. Records of the meals served over the past couple of months were viewed and showed a varied menu, with choices available at both lunch times and teatimes. There were a good variety of hot and cold choices of food available at tea times, and the cooks are commended for taking the time and effort to make home-made soups. Residents spoken to were all positive about the meals served to them. In relation to the serving of meals, the home had now obtained a side-board for each lounge, in which to store crockery and cutlery. These appeared much more homely and appropriate than previous arrangements for storing crockery. However, some staff reported finding the low level of these cupboards was Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 12 uncomfortable for accessing crockery at frequent intervals during the day: the manager was advised to review arrangements for accessing these cupboards with staff, and to carry out risk assessments on the task as necessary. Residents spoken to confirmed that they felt that they had choices in their daily lives (e.g. where and how to spend their day, what to eat, when to go to bed, etc.). On the day of the inspection, some had had a bath during the afternoon and returned to the lounges in their night clothes and dressing gowns: whilst they reported that they had enjoyed their bath, two residents spoken to said that they would rather not have been dressed in their bed clothes during the afternoon and whilst sitting with other people in a communal area. They were not aware that they had a choice in this, and a senior carer and the manager were asked to ensure that staff make it clear to residents in future that it is their choice how they dress after a day-time bath. The manager currently assists one resident with their finances (acting as agent to cash pension cheques or pay cheques into their bank account if required), and provided appropriate support to enable them to maintain some control over their affairs (e.g. taking them to their bank when they needed to withdraw money). Family members managed other residents’ financial affairs. It had been noted on previous inspections that information on access to records was provided in the Residents’ Handbook in each person’s room, and that residents were able to bring their own possessions into the home with them. Information on an advocacy service was displayed in the home, and the manager stated that this service had previously been accessed on one person’s behalf. Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has an appropriate procedure for responding to complaints, but the home’s complaints’ record did not provide satisfactory evidence of how complaints were investigated or resolved. The home promotes the protection of service users through its policies and procedures and through staff training; however, evidence of training to promote staff awareness of protecting residents from abuse was not yet sufficient to demonstrate that all staff had received this training. EVIDENCE: The home has a company complaints procedure that meets regulatory requirements, incorporating timescales for response and the CSCI contact details. This was displayed in the home, and the manager confirmed that it is also included in the Residents’ Handbook. Complaints were recorded in a hardback bound notebook, with pages divided to provide space to record an appropriate summary of each complaint, including the investigation/action taken, and the outcome. There was only one complaint recorded in this book, and this did not show the action taken or the outcome: the manager explained that this had been investigated by a senior manager in the organisation, and was advised that the records in the home still need to show the action and outcome. Similarly, a further complaint received had been sent to the registered provider: although the manager had spoken to the complainant and addressed the issue, this complaint had not been recorded in the home’s records and the manager did not know whether the provider had also responded. The manager was aware of a recent complaint sent to the registered provider, but did not have a record of this in the home. The Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 14 manager was advised that a record of all complaints should be kept in the home, summarising the action taken and the outcome, with copies of any response from the registered provider placed on the resident’s file as appropriate. At the last inspection the provider was required to make arrangements to ensure that training in the protection of vulnerable adults was provided to any staff who had not previously attended this training. This was reviewed on this occasion: training already planned at the last inspection had now taken place, with 9 staff attending POVA training in September and November 2005; however, no other training had taken place with the remainder of the staff identified at the last inspection as still requiring this training (plus any new staff recruited since then, including domestic staff). It is therefore recommended that this be addressed as soon as possible. Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 At the time of this inspection, areas of the home inspected were clean and pleasant, and appropriate facilities were in place to promote good hygiene in the home. EVIDENCE: Infection control policies were not inspected on this occasion, although it was confirmed that the home had a copy of guidance on infection control on care homes (issued by the Health Protection Agency). The home had appropriate facilities and equipment available for staff (e.g. paper towels, liquid soap, disposable protective gloves and aprons, etc.). Laundry facilities were away from areas where food was stored or prepared, and the manager was confidant that the washing machine’s ‘sanitary cycle’ met infection control requirements regarding washing temperatures. A hand wash-basin was available in the laundry area, and there was an adjacent sluice room containing a flushable porcelain sluice sink and a hand wash basin. On the day of the inspection the communal areas of the home viewed were clean and tidy, and were free from any unpleasant odour. Domestic staffing levels had considerably improved since the last inspection (see also standard 27), which is commended. Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 29 At the time of this inspection, service users’ needs were being met by the agreed care staffing numbers and skills. Recruitment practices protected residents, but evidence held in the home did not fully demonstrate all the checks required by regulation. EVIDENCE: A range of staff rotas were viewed from over the previous two months. These showed that agreed staffing levels had generally been maintained, with morning staffing levels reduced from seven to six staff whilst the home was below occupancy. Following the increase in the number of beds in the home last year, a condition was attached to the home’s registration to require that staffing levels were reviewed with the CSCI within six months of registration of three months of full occupancy. In view of the current low occupancy levels within the home it was therefore agreed to defer this review until occupancy exceeds the previous registered number of residents. From rotas seen, there were some occasions when the afternoon staffing levels had dropped from six to five staff: the manager stated that at the current occupancy levels, five staff could manage, but recognised that such minimum staffing levels allowed no lee-way if there were last minute staff absences. The manager said that he had therefore implemented contingency plans (a named member of staff on stand-by) in case there were any further last minute absences. This is commendable, and the manager was advised to Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 17 ensure that the stand-by person’s name was clearly recorded in the office, so that other staff were aware of who to contact. It was noted that several care staff were still working two or three long days per week, including two successive long days on regular occasions. Staff spoken to were very clear that this was their choice, but the manager was advised that he must monitor this closely to ensure the health, safety and welfare of both staff and residents is not affected by staff getting over tired. The manager confirmed that he was aware of the need to ensure that there was sufficient cover on the floor when staff working long days took their breaks. Several domestic staff had been recruited since the last inspection, and it was noted from recent rotas that domestic staffing levels were now satisfactory. This was good to see. The files of one new carer and one new domestic assistant were inspected for evidence of recruitment practices. Both files contained evidence of identification and completed application forms showing employment history, names of referees, medical questionnaires, and a criminal declaration. In one case there was evidence that both references had been received before the person started work. In the other file there was no evidence of any references received: the manager subsequently advised the inspector that these were at the home’s head office; evidence of these should be held at the home. Both files contained evidence of a POVAfirst check received before the person started work, and one file contained evidence that the full CRB check had been received a few weeks after they started work. The other file contained no evidence that a CRB check had been received, although the manager subsequently confirmed that the head office had received this. The manager was advised of the need to provide evidence on file that CRB checks have been received: he confirmed that the home’s head office usually provide this, and was able to provide evidence for another carer that this was the case. Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 38 The home had systems in place for monitoring that the home was run in the best interests of residents. Residents’ financial interests were safeguarded by the home’s practices and procedures for looking after money on their behalf. Records of health and safety practices did not provide sufficient evidence to demonstrate that all aspects of the health and safety of service users and staff were satisfactorily promoted within the home. EVIDENCE: On the day of the inspection the home appeared to be running smoothly and calmly, and staff were clear on their areas of responsibility. Several of the staff and residents spoke positively about the manager of the home, finding him approachable and supportive. The manager reported that since the last inspection he had held six staff meetings with various groups of staff (seniors, care staff and domestics), and was encouraged to continue developing systems for communicating within the staff team. Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 19 A survey of residents’ views on the home had been carried out by an independent consultant in April/May 2005, following which a report had been produced summarising the outcomes and making a number of recommendations. Questionnaires had been sent to residents, and where residents were unable to respond a relative or friend had been asked to assist. No action had been subsequently taken to address recommendations made from this, and this was discussed with the manager. The home does not currently have an annual development plan for 2005-2006, and the manager was not aware if one would be developed for 2006-2007. He was advised that this should be implemented, and that any issues arising from residents’ surveys could be incorporated into the aims and objectives for the year. In terms of self-auditing practices within the home, a representative from the organisation carried out regular monitoring visits as required under Regulation 26, and produced written reports on these. Within the home there was evidence of the monthly monitoring of accidents, and of a variety of health and safety/maintenance checks taking place (see standard 38). The manager stated that medication records and supplies are regularly checked, but there is no system at present for recording this. The manager advised that the training manager was in the process of implementing a National Minimum Standards Self-Assessment form for each home, and that they are also considering carrying out regular themed monitoring exercises within the home. Although not currently in place, both these proposals demonstrated positive and practical forms of self-monitoring, and would significantly add to the home’s quality assurance processes. The home has secure storage facilities and is willing to look after small sums of money on behalf of residents. The home also has a shared residents’ bank account for the safe keeping of larger amounts of money, but the manager stated that this is not currently used by any resident. Clear individual record sheets and receipts were kept for any monies looked after for residents, and a sample checked for one resident showed that cash held, records and receipts balanced. The registered manager is only an agent (counter-signatory) for one resident, to assist them to manage their finances. The home’s policies and procedures on health and safety were not inspected on this occasion. The manager maintained a record of all checks and servicing carried out on equipment and utilities, providing evidence that the equipment and premises were regularly maintained. There were also records of internal checks on fire alarms, emergency lighting, and hot tap water temperatures (re risk of scalding): however, these records were inconsistent, with frequent gaps where weekly/monthly checks had not been recorded. An unregulated kitchen hot water tap was checked as an indicator whether hot water was stored at over 60°C to prevent risk of Legionella: records showed temperatures lower than 60°C, and the manager should seek advice as to whether these temperatures are within an acceptable range in relation to the distance of the Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 20 outlet from the tank. The manager stated that fire drills were held monthly, and a record of the most recent drill was seen; the manager confirmed that issues highlighted by a recent fire officer inspection were being actioned. A recent Environmental Health officer inspection had highlighted two areas for further action, but evidence was not available to demonstrate that action had been taken to address these issues. Accident records were maintained, and there was good evidence that these were monitored monthly, and on an individual resident basis if required. There were risk assessments available on some specific risks (e.g. summer barbecue, recent building work, etc.), and also a fire risk assessment; it was noted that the recent fire officer inspection report had identified an issue that they recommended should be considered as part of this assessment. The manager was unable to locate any other general risk assessments on safe working practices within the home. From a central staff training summary it appeared that not many staff had attended recent fire safety or food hygiene training, and the manager confirmed that there had been no further training in these subjects since the last inspection. The maintenance person was a trained fire marshall and carried out an introductory fire safety session with new staff on induction; evidence of a completed checklist showed the areas covered on this session. First aid and moving and handling training records were not inspected on this visit: the manager is a manual handling trainer, and confirmed that a training session had taken place on the previous day at another local home. Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 X X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 15 Requirement It is required that care plans are developed further to ensure that they contain clear details of the action required to meet each residents individual needs (physical and mental health and social/recreational needs). This is a repeat requirement for the third time (last timescale 31/10/05). Staff should ensure that all medication administration instructions recorded on the MAR reflect current GP instructions. This is a repeat requirement for the second time (last timescale 12/09/05), and particularly relates to ensuring handwritten entries record the size and frequency of dose. The registered person must ensure that medication is stored in accordance with instructions. This particularly relates to: (a) medication that should be stored in a fridge, and (b) medication that should be discarded 28 days after opening. DS0000017911.V282797.R01.S.doc Timescale for action 31/03/06 2. OP9 13 28/02/06 3. OP9 13 24/02/06 Poplars Version 5.1 Page 23 4. OP16 22,17,Sch 4.11 5. OP29 19 6. OP38OP30 18 and 13 7. OP38 13 The registered person must maintain in the care home a record of all complaints made by service users or representatives of service users or persons working at the care home, and the action taken by the registered provider in respect of any such complaint. The registered person must ensure that the home can evidence that all documentation required by regulation has been obtained for new staff before they start work. This is particularly with regard to references, and evidence of receipt of CRB check. All staff must receive regular training updates in relevant areas of health and safety (e.g. food hygiene and fire safety). This is a repeat requirement for the second time (last timescale 31/12/05). The registered person must ensure that risk assessments are carried out and recorded for all safe working practices within the home. 28/02/06 28/02/06 31/05/06 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations The registered person should ensure consistent practice with regard to the recording of ‘as required’ medication (i.e. whether a record is made when this is not required). Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 24 2 OP14OP10 3 4 OP18 OP27 5 6 7. 8. OP33 OP33 OP38 OP38 Staff should ensure that residents are always offered a choice of what clothes to put on following an afternoon bath, in order to promote their privacy and dignity when spending time in communal areas. The registered person should make arrangements to ensure that any remaining staff who have not yet attended POVA training receive this training as soon as possible. The registered person should closely monitor the number of long days worked by some staff, and ensure that the length and pattern of their working week does not affect their capacity to safely fulfil their responsibilities. It is recommended that action is taken to address recommendations arising from the survey of residents’ views on the care home. It is recommended that the home implement an annual development plan, reflecting aims and outcomes for service users. The registered person should ensure that internal checks on fire alarms, emergency lighting, and hot tap water temperatures are regularly carried out and recorded. The registered person should ensure that action is taken to meet requirements or recommendations identified by the Environmental Health Officer. Poplars DS0000017911.V282797.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 DS0000017911.V282797.R01.S.doc Version 5.1 Page 26 - 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!