Inspection on 23/06/05 for Poppy Lodge

This inspection was carried out on 23rd June 2005.

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

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

Other inspections for this house

Poppy Lodge 29/05/07

Poppy Lodge 07/11/06

Poppy Lodge 01/12/05

Poppy Lodge 04/11/04

Poppy Lodge 13/07/04

Poppy Lodge 30/03/04

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Polesworth Group Pooley Heights

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Polesworth Group 70 Long Street

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

CARE HOME ADULTS 18-65 Poppy Lodge 633 Church Road Yardley Birmingham B33 8HA Lead Inspector Gerard Hammond Unannounced 23 June 2005 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 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 Stationary 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. Poppy Lodge E54 S17128 Poppy Lodge V235438 230605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Poppy Lodge Address 633 Church Road Yardley Birmingham West Midlands B33 8HA 0121 628 3718 0121 628 3718 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Saeeda Younus Mrs Saeeda Younus Care Home 3 Category(ies) of Younger Adults, Learning Disability (3) registration, with number of places Poppy Lodge E54 S17128 Poppy Lodge V235438 230605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 4 November 2004 Brief Description of the Service: Poppy Lodge is currently registered to provide accommodation, care and support for 3 people with learning disabilities. The Registered Manager is also the owner of the Home. An application to increase the number of places to 4 has recently been made to CSCI. At the present time, all of the residents are male. The property is a large detached house situated in the residential district of Yardley in Birmingham. A range of local amenities and community facilities are available close by, and the house is well served by public transport. On the ground floor there is a through lounge / dining room which gives access to the rear garden through patio doors. There is a large kitchen: adjacent to this is a sizeable lean to, which houses the laundry facilities. There is a downstairs bedroom with en-suite bathroom, and a further w.c. Upstairs there are three single bedrooms occupied by the current residents. All have wash hand basins, but none have en-suite facilities. There is a small bathroom with over-bath shower, and a separate w.c. The office and staff sleep-in room are also on this floor. At the front of the house is a good-sized drive offering off-road parking. To the rear of the property is a large private garden. Poppy Lodge E54 S17128 Poppy Lodge V235438 230605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Direct observation and sampling of records (including personal files, care plans and safety records) was undertaken for the purposes of compiling this report. The Inspector met all three residents and formally interviewed the Manager / Homeowner. Two other members of staff were interviewed informally. What the service does well: What has improved since the last inspection? The Manager has now completed her NVQ level 4, and achieved the Registered Manager’s Award. In addition to this, a good deal of work has been done since the last inspection in order to meet requirements, with about 85 being completed. Considerable thought has gone into developing residents’ care plans and risk assessments. Staffing levels have been improved, and active consideration is being given to ways of extending this further. Recruitment practice has also improved, and work on policy and procedure development is ongoing. The installation of hand-washing facilities in the laundry area has contributed to improved infection control. Poppy Lodge E54 S17128 Poppy Lodge V235438 230605 Stage 4.doc Version 1.40 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. Poppy Lodge E54 S17128 Poppy Lodge V235438 230605 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Poppy Lodge E54 S17128 Poppy Lodge V235438 230605 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 4, 5 Information is available to support prospective residents in making a decision with regard to future placement, but some items require minor adjustment. Residents’ support needs are assessed appropriately, and this is supplemented by the opportunity to come and stay at the Home before making any decision about taking up a placement. Each resident has an individual contract outlining terms and conditions, in writing. EVIDENCE: There have been no new admissions since the time of the last inspection. Work has been done to develop the Statement of Purpose, but minor adjustments are still required, including updating staff information and incorporating the amended complaints procedure into the document. It was recommended that additional information be included about activities currently undertaken by residents, as well as an indication of community facilities and amenities available locally. Personal files provided evidence of appropriate assessments of individuals’ support needs, and a conversation with the Manager confirmed that any prospective resident would be offered the opportunity to visit and to stay at the house, prior to any decision being made about future placement. Poppy Lodge E54 S17128 Poppy Lodge V235438 230605 Stage 4.doc Version 1.40 Page 9 Residents’ contracts have been amended as required: it was recommended, as a matter of good practice, that contracts offered the option of being countersigned by a relative or appropriately independent person, where residents are unable to sign for themselves. Poppy Lodge E54 S17128 Poppy Lodge V235438 230605 Stage 4.doc Version 1.40 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 standard(s) 6,7, 8, 9 Residents’ care plans reflect their support needs adequately and are being developed appropriately. Staff support residents to make decisions, seek to consult with them and help them participate in the day-to-day running of the Home. Residents are supported to take risks in a responsible manner, but risk assessments need to be linked directly to care plans. EVIDENCE: Good work has been carried out to develop residents’ care plans, and this should now be built upon. There is clear evidence of efforts to review and to evaluate plans appropriately and this is to be commended. The staff team should be encouraged in their efforts by developing further clear goals for each resident across every identified area of support need. It is recommended that a definite strategy be introduced to develop Person Centred Planning, in accordance with the aspirations of the Government’s White Paper “Valuing People”. Risk assessments should be cross-referenced to the component(s) of the care plans to which they relate, and vice versa. These should be reviewed in Poppy Lodge E54 S17128 Poppy Lodge V235438 230605 Stage 4.doc Version 1.40 Page 11 conjunction with the whole care plan at least every six months, or as necessary. There is evidence of residents being encouraged to take risks appropriately, and members of staff try hard to involve each person in day-today matters about the house, according to their abilities. Staff were observed offering choices appropriately to residents and encouraging them to make their own decisions. Poppy Lodge E54 S17128 Poppy Lodge V235438 230605 Stage 4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16, 17 Residents receive support for personal development through structured and informal activity programmes. They have access to an appropriate range of activities and use facilities in the local community on a regular basis. Residents are also supported to maintain contact with their families and friends, and their rights and responsibilities are respected and encouraged. They enjoy both choosing their own food and a healthy, balanced diet. EVIDENCE: Conversations with the Manager and records sampled indicated that work is going on with residents at home to develop skills (reading and writing) as part of individuals’ activity schedules. In addition to this, all residents have structured day activity programmes at local centres and colleges. One resident also has a day placement working in a local shop. Residents are encouraged to be active and they access local leisure centres and parks for exercise. One of the residents particularly enjoys going to the park to ride his bicycle. People also go to the cinema, local pubs, restaurants and shops. They also enjoy watching films on DVD and video at home. Poppy Lodge E54 S17128 Poppy Lodge V235438 230605 Stage 4.doc Version 1.40 Page 13 Contact with relatives and friends outside the home is actively supported. The Manager has gone out of her way to establish and maintain contact with one of the resident’s relatives in Ireland, and plans are afoot to support him to go and visit his family there, as soon as this can be arranged. Another resident has a sister living close by, and visits her most days. Residents also play an active role in doing the grocery shopping for the house, so that they are enabled to choose directly food items that they particularly like. The record of meals taken was seen, and provided evidence of a good variety and balance in people’s diets: this was further supported by an examination of food stocks, which included ample supplies of fresh produce. One of the residents returned home during the day and had lunch, complimenting staff on how much he enjoyed it. Poppy Lodge E54 S17128 Poppy Lodge V235438 230605 Stage 4.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 Residents receive support in a friendly and respectful manner, in accordance with their needs and wishes. Their physical and emotional health needs are met appropriately. No residents currently take regularly prescribed medication. EVIDENCE: Residents are generally independent in most aspects of their personal care, only requiring verbal prompting in the main. A requirement made at the time of the last inspection with regard to servicing door locks has been met. Staff were observed giving support in an appropriately respectful manner, and it is clear that both staff and residents are at ease in each other’s company. Residents are supported to access health care appointments with the GP, dentist and optician, and referrals are made appropriately to members of the multi-disciplinary team, as and when necessary. There are some concerns over the apparent deterioration in the mental health of one of the residents, and this situation is currently being monitored by staff. None of the residents is taking regularly prescribed medication at present. Poppy Lodge E54 S17128 Poppy Lodge V235438 230605 Stage 4.doc Version 1.40 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 standard(s) 22, 23 An appropriate formal complaints procedure is now in place, and residents know that they can complain and be heard. General policy and practice within the Home affords residents with protection from abuse, neglect and self-harm, but it is not possible to assess this standard fully in the absence of an up to date staff training and development assessment. EVIDENCE: A requirement was made at the time of the last inspection that the complaints policy should be further developed to include information about how to make a complaint and to whom, what to do if not satisfied, the role of CSCI and the Ombudsman, and assurance that no-one is victimised for making a complaint. All this information has now been incorporated into the amended policy. It is also clear from direct observation that residents are able to voice any concerns with the Manager, and are quite comfortable doing so. A further requirement was made in respect of the policy on adult protection, and this has now also been amended in line with directions given. It was not possible to ascertain completely the degree to which the staff team has been trained in this regard, and this will be assessed more fully at the next inspection. Recruitment procedures support the protection of people living in the house. (See Standards 34 & 35 also.) The Manager advised that some training has been undertaken by two members of staff. Poppy Lodge E54 S17128 Poppy Lodge V235438 230605 Stage 4.doc Version 1.40 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 standard(s) 24, 30 Residents at Poppy Lodge enjoy living in a house that is spacious, comfortable, homely and safe. A good standard of hygiene is maintained, and the house kept clean and tidy. EVIDENCE: Residents at Poppy Lodge are comfortably accommodated in a house that is roomy and adequately furnished at present. It was observed at the last inspection that décor and fixtures and fittings would require upgrading in the near future. This continues to be the case, though it must be acknowledged that the owner has signified her commitment to developing and maintaining the quality of the home environment, when available resources permit. This stance is supported by substantial expenditure on improving the rear garden for the benefit of the residents. People’s bedrooms were seen to be quite individual, and personal possessions and effects were much in evidence. The Home is kept clean and tidy, and a good standard of hygiene maintained. A previous requirement to provide hand-washing facilities in the laundry area has now been met. Poppy Lodge E54 S17128 Poppy Lodge V235438 230605 Stage 4.doc Version 1.40 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35, 36 Recruitment policy and practice within the Home provides an appropriate level of support and protection for the residents. A detailed staff training and development assessment is required to ascertain whether or not the staff team is appropriately trained. Resident’s benefit from a staff team that is well supervised and supported. EVIDENCE: A sample check was undertaken of the staff records for the most recently recruited employee. All necessary documentation was in place, including CRB and POVA list checks. A requirement was made that the Manager submits to CSCI a detailed analysis of staff training needs. This should include details (for each member of staff) of all training and qualifications undertaken and achieved to date. It should also indicate what refreshers are due and when, and identify all other training needs for each person. The schedule should include a timetable to show when training is to be arranged, and who will deliver it. The relatively small size of the Home means that supervision of staff on a dayto-day basis can be easily facilitated. Examination of other staff records indicated that group staff meetings and formal supervision on an individual basis meet the requirements of this standard. Poppy Lodge E54 S17128 Poppy Lodge V235438 230605 Stage 4.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 42 Residents benefit from the support of a Manager who is appropriately qualified, and whose management style is open and inclusive. Formal quality assurance and monitoring systems should be put in place so that it can be clearly seen that residents’ views underpin the development of the service. General practice within the Home promotes the protection, health and safety of the residents. Some policies and procedures are however in need of review and slight amendment, in order to meet standards fully. EVIDENCE: The Manager advised that she has now completed the Registered Manager’s Award and NVQ level 4, and is waiting to receive her certificates. Poppy Lodge E54 S17128 Poppy Lodge V235438 230605 Stage 4.doc Version 1.40 Page 19 The atmosphere in the Home is very relaxed, and it is quite apparent that residents and staff find the Manager to be an approachable person, and that her style of management is both open and inclusive. While it is apparent that residents appear comfortable in airing their views with the Manager, there is no formal process in place for monitoring or evaluating the quality of the service at Poppy Lodge. Appropriate systems for achieving this need to be developed, and this will be assessed more fully at the next inspection. At the time of the last inspection, requirements were made in respect of some of the Home’s policies and procedures. The Fire Policy and Missing Persons Policy have been developed and amended as required. However, the policy relating to Physical Interventions is yet to be dealt with. This policy makes reference to the use of restraint. To date, no staff has been trained in the appropriate use of such techniques. Either suitable training must be provided for all members of staff working in the house, or this element of the policy should be removed if restraint is not to be used, subject to appropriate risk assessment and care planning. A sample check of safety records was undertaken. Tests of fire alarms and extinguishers, and emergency lights had all been carried out and recorded appropriately. Fire drills have also been carried out regularly. A fire risk assessment has been completed, but this had no date or any indication of when it was last reviewed. Temperature checks on hot water outlets, and on the fridge and freezer have been completed as required. Portable appliance testing of electrical equipment has been carried out, and the hard wiring certificate is in date but will require renewing shortly. The COSHH cupboard was inspected and found to be secured appropriately. Poppy Lodge E54 S17128 Poppy Lodge V235438 230605 Stage 4.doc Version 1.40 Page 20 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 2 3 x 3 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Poppy Lodge Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 3 2 2 x 3 x E54 S17128 Poppy Lodge V235438 230605 Stage 4.doc Version 1.40 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4 (1c) & Sch.1 Timescale for action Update the Statement of Purpose 31.08.05 to include current staff information and complaints procedure. Provide detail of activities and local facilities and amenities Cross-reference care plans and 31.08.05 risk assessments, and ensure that they are reviewed at least every six months. Reviews should be recorded in writing, indicating who takes part and how decisions are made. Ensure that all staff receive 30.09.05 training in the Protection of Vulnerable Adults From Abuse Produce a schedule for planned 30.09.05 maintenance and refurbishment of the Home and forward to CSCI Submit a copy of the staffing risk 31.08.05 assessment, including lone working arrangements, as required at the inspection on 04 November 2004 (not available at this inspection) Submit a detailed staff training 30.09.05 and development assessment to CSCI, as indicated in the main body of this report. Review the Physical Intervention 31.08.05 Policy in conjunction with Version 1.40 Page 22 Requirement 2. 6&9 12 (1a) & 15 and 13 (4a-c) 3. 4. 5. 23 24 33 13 (6) 23 (2b) 18 (1a) 6. 35 12 (1a) & 18(1a) 13 (6) 7. 40 Poppy Lodge E54 S17128 Poppy Lodge V235438 230605 Stage 4.doc 8. 42 13 (4a-c) residents assessments and care plans, and either remove references to the use of restraint, or make arrangements for staff to be suitably trained, as appropriate. Review the fire risk assessment. This should be signed and dated at the time of review. 31.08.05 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. Refer to Standard 5 6 Good Practice Recommendations Provide facility in residents contracts for countersignature by relative or other independent person, where resident is unable to sign. Develop a strategy to implement person-centred approaches, in accordance with Valuing People Poppy Lodge E54 S17128 Poppy Lodge V235438 230605 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ 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. 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