Inspection on 09/02/07 for Poplars

This inspection was carried out on 9th February 2007.

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 01/12/08

Poplars 11/01/08

Poplars 29/11/05

Poplars 22/07/05

Poplars 18/06/04

Poplars 23/09/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Poplars Poplars 15 Ickenham Road Ruislip Middlesex HA4 7BZ Lead Inspector Ms Susan Woolnough-Singh Unannounced Inspection 9th February 2007 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 DS0000027119.V324809.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 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 DS0000027119.V324809.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Poplars Address Poplars 15 Ickenham Road Ruislip Middlesex HA4 7BZ 01895 635 284 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) Appcourt Limited Trading as: Ms Debra Fairholme Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Poplars DS0000027119.V324809.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home shall not accommodate Severely Mentally Infirm residents Date of last inspection 29th November 2005 Brief Description of the Service: The Poplars is a care home registered for 27 older people. The home is on three floors; there is a lift in place. The home is situated in the centre of Ruislip, close to shops and public transport. There is a large rear garden and a large parking area to the front of the home. All bedrooms are single and have en suite facilities. A new staff room and laundry have been built to the rear of the property since the last inspection. Two new single bedrooms have also been provided at the rear of the building on the ground floor. The number of service users accommodated has not changed. The weekly fees for the home range from £420 - £585 per week. There are additional charges for hairdressing, chiropody, toiletries and newspapers. Poplars DS0000027119.V324809.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of Poplars Care Home Home. The Inspection took place on 9th February between 10am and 16.15. All of the Key National Minimum Standards for Older People were assessed. The Inspector carried out a tour of the home and inspected service user plans. Three service users were spoken with individually, two of who were able to give their opinion on the quality of care provided in the home. Two relatives were spoken with. Information given on the pre inspection questionnaire completed by the Registered Manager was also used to compile this report. Six comment cared were received from relatives and visitors and eleven questionnaires were completed and returned by service users. The Inspector carried out the inspection with the assistance of the Registered Manager. What the service does well: What has improved since the last inspection? What they could do better: The Registered Provider and Manager need to ensure that an annual quality audit takes place, this must include service user consultation. Photographs of staff need to form part of their personnel file. Poplars DS0000027119.V324809.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Poplars DS0000027119.V324809.R01.S.doc Version 5.2 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 DS0000027119.V324809.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users only move into the home once their needs have been assessed. EVIDENCE: The files of three service users were examined. These contained assessments; a needs led assessments carried out by the Local Authority and a Poplars assessment if the service user is on a private contract. The Registered Manager reported that a full medical history was now being requested. Poplars care home does not offer a programme of intermediate care for service users. Poplars DS0000027119.V324809.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plan provides information on the personal care and health of service users. Procedures and training are in place for the safe handling of medication. Staff endeavour to maintain the privacy of service users. EVIDENCE: The care plans of four service users were examined. These contained all the necessary information such as a service user plan and daily records. The care plan covered guidance for staff on service users daily care such as personal care, physical well being, mobility, dexterity, mental state and cognition and social and religious needs. One care plan stated that the service Poplars DS0000027119.V324809.R01.S.doc Version 5.2 Page 10 user should be encouraged to maintain independence; the detail of this was brief. It is to be recommended that more written detail on how the service user can be assisted to maintain their independence is added to the care plan. Service users are able to see a range of health care professionals who visit the home. Visits are recorded on service users files. Files indicated that were relevant service users had been referred to specialist health care professionals. Senior staff are responsible for the administration of medication. Staff have received training in the safe handling of medication and at the time of the inspection senior staff were on a distance learning course ‘Managing and Safe Handling of Medication. Medication is stored and administered from Blister Packs. The Medication room, cabinet and medication administration records were found to be in order. The Inspector spoke with three service users, two of whom were able to give their opinion on staffing in the home and privacy. Service users felt that staff respected their privacy and knocked on the bedroom door. The relatives spoken with could not comment on this but said they had observed that staff attended to service users when they were needed. Poplars DS0000027119.V324809.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities are available for service users in the afternoon. Service users would benefit from consultation on the activities provided. Service users are able to receive visitors in private and are able to exercise some choice with regard to their daily routines. Service users are provided with a balanced diet, which they are satisfied with. EVIDENCE: One member of staff is allocated each afternoon for activities in the home. One service user commented how good the Christmas celebrations had been. Activities provided at the home are bingo, quiz and board games; there is a musical morning. Service users spoken with confirmed that activities take place. Written feedback from relatives and services about activities was mixed, some feeling that not enough was provided. The television screen in the Poplars DS0000027119.V324809.R01.S.doc Version 5.2 Page 12 lounge is small; a service user and relative/visitor highlighted this on the comment cards. The feedback received from relatives was that service user could be visited and seen in private. Service users can go to Darby and Jone Club, but according to information provided, refuse to go. The two service users spoken with said that they make choices within the routine of the home. Both service users preferred to stay in their bedroom. Overall, service users and relatives said that they were satisfied with the care provided. A cook is employed at the home. There is a choice of main meal at lunchtime. Supper consists of sandwiches, soups and snack foods. Meals on the menu are mainly traditional British dishes. Feedback received form service users and relatives indicated satisfaction with the meals provided. There is a separate dining area; the tables are nicely set at meal times. Poplars DS0000027119.V324809.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A complaints procedure is in place for service users and relatives/visitors. Training is in place for staff on safeguarding adults. Policies and procedures in safeguarding adults are activated if necessary. EVIDENCE: The home has a complaints procedure. The procedure had been updated and had the new CSCI address for West London. The home had received one complaint and this had been resolved. Service users in their written feedback indicated that they knew how to make a complaint. Some relatives and visitors were aware of the complaints procedure others were not. The Registered Manager discussed with the Inspector a safeguarding adults issue, this had been dealt with appropriately. There is an adult protection policy in the home; the Registered Manager and Senior Carer train staff as part of the induction in safeguarding adult’s policies and procedures. Poplars DS0000027119.V324809.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is suited to its stated purpose. Service users bedrooms are being improved to offer more comfort. The home is clean and well maintained. EVIDENCE: The Poplars provides a well-maintained environment for service users. Accommodation comprises of a spacious lounge and separate dining room; there are twenty-seven single rooms with basic en-suite (toilet and wash hand basin). There are two bathrooms. There is parking to the front of the home; at the rear are gardens and a laundry. In feedback from relative’s/visitors, dissatisfaction with the laundry system was expressed. Service user clothes are not always accounted for. A programme of refurbishing service users bedroom was taking place. Six bedrooms had been refurbished to date. A Poplars DS0000027119.V324809.R01.S.doc Version 5.2 Page 15 number of these bedrooms were viewed by the Inspector and the decoration, and refurbishment was judged to be to a very high standard. All areas of the home were clean and well kept on the day of the inspection. One comment was made that the hall close to the entrance sometimes has an undesirable odour. Poplars DS0000027119.V324809.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28.29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff on duty meets Service users daily needs. Staff are offered the opportunity to undertake NVQ training in care to improve their skills in residential care work. Mechanisms are in place to ensure that prospective employees are suitably checked when recruited. EVIDENCE: The staff team at Poplars consists of fourteen care staff, one cook and two domestic workers. Four care staff and one senior carer are on duty in the morning, with three care staff and one senior carer on duty in the afternoon/evening. Care staff prepare the breakfast and the evening meal. The home has assessed dependency levels as thirteen service users with medium needs and fourteen with low needs. All twenty-seven-service users need help with washing and bathing and over half with dressing and undressing. Service users and relatives spoken with confirmed that their care needs were being met. Poplars DS0000027119.V324809.R01.S.doc Version 5.2 Page 17 Three staff have NVQ 2 with three staff in the process of completing NVQ 2. Four staff had been registered with Uxbridge College and had started NVQ training on 21st January 2004. Three staff with NVQ training had left the home since the last inspection. Staff training on health and safety, moving and handling, fire drill, food hygiene and managing challenging behaviour is provided The Registered Manager carries out one to one supervision with staff; the files seen indicated that one member of staff had received supervision in January 2007 and one member of staff had only commenced employment recently had had not had his/her first supervision session. The personnel files of two relatively new members of staff were examined. The required documents were on file although one file did not have any identity verification in the form of a photograph. Poplars DS0000027119.V324809.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35, and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the skills and experience to manage the home. Service users are given the opportunity to put forward their views on the home. The home at present is not audited for quality assurance on an annual basis. The home is not responsible for the management of service users financial affaires. Poplars DS0000027119.V324809.R01.S.doc Version 5.2 Page 19 EVIDENCE: The Registered Manager has worked at the home for a number of years and has the competence and experience to fulfil her role. The Registered Manager has just completed her NVQ in Management of Care. Surveys are sent out to stakeholders, service users and their families asking for their view on the quality of care. Further surveys were due to be sent out in 2007. A full Quality Assurance System is not in place. An internal audit of care standards does not take place annually. A Quality Assurance System must be introduced and become part of the management systems. The home only manages relatively small amounts of money for service users. This is usually for everyday requisites; service users family provide money for these and are given a receipt by staff. The Registered Manager was aware of her responsibilities and boundaries with regard to the management of service users finances. A small number of service user are able to manage their financial affairs. The home provided information in the form of a pre -inspection questionnaire. Dates of equipment and utility servicing were given. Maintenance checks had taken place in 2007. The last fire drill was on the 18th January 2007. Staff training had taken place in health and safety related subjects. The Registered Manager confirmed that health and safety audits take place on a monthly and quarterly basis; records of these were not sampled on this occasion. Poplars DS0000027119.V324809.R01.S.doc Version 5.2 Page 20 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 3 X x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 X X x 3 X x 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 3 Poplars DS0000027119.V324809.R01.S.doc Version 5.2 Page 21 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 2 Standard OP26 OP27 Regulation 16 (2) (k) 18 Schedule 2 1, 24 Requirement The odour problem identified on the ground floor must be resolved. All staff records must include a recent photograph. Previous timescale of 16th January 2006 not met. The Registered Person must establish a system for reviewing the overall quality of the service provided in the home. Timescale for action 01/04/07 01/04/07 3 OP33 01/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. 3. Poplars Refer to Standard OP19 OP26 OP27 Good Practice Recommendations The television available in the lounge area should be replaced with a large screen, which can be viewed by all service users. Odour control in the ground floor area should be improved. The management of the launderette should be monitored. DS0000027119.V324809.R01.S.doc Version 5.2 Page 22 Poplars DS0000027119.V324809.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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