Inspection on 07/11/06 for Poppy Lodge

This inspection was carried out on 7th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 22 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Poppy Lodge 29/05/07

Poppy Lodge 01/12/05

Poppy Lodge 23/06/05

Poppy Lodge 04/11/04

Poppy Lodge 13/07/04

Poppy Lodge 30/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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 West Midlands B33 8HA Lead Inspector Kulwant Ghuman Key Unannounced Inspection 7th November 2006 10:30 Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Poppy Lodge Address 633 Church Road Yardley Birmingham West Midlands B33 8HA 0121 628 3718 F/P 0121 628 3718 poppylodge@yahoo.co.uk 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) Mrs Saeeda Younus Mrs Saeeda Younus Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 1st December 2005 Brief Description of the Service: Poppy Lodge is currently registered to provide accommodation, care and support for 4 people with learning disabilities. The Registered Manager is also the owner of the Home. 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 separate toilet. Upstairs there are three single bedrooms. One has a wash hand basin and access to a toilet and bathroom on the first floor. The other two bedrooms have en-suite facilities of toilet, wash hand basin and shower. The main office is based on the first floor. At the front of the house is a goodsized drive offering off-road parking. To the rear of the property is a large private garden. At the time of this inspection there was a double storey extension being built on at the side of the home where the laundry facilities had previously been sited. An application to increase the home’s registration numbers from 4 to 6 residents was in place. The laundry facilities were currently sited on the patio area at the back of the home. At the time of writing this report information about the fee levels was not available. Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this key unannounced inspection over a day in November 2006. At the time of the inspection the manager was on duty and the staff assisted the inspector. There were four residents living at the home and the inspector spoke with two of them and a visitor as well as two members of staff. As part of the inspection process the inspector toured the building, looked at residents care plans, three staff files and some health and safety records. No complaints had been received by the Commission about this service. What the service does well: What has improved since the last inspection? The home has worked hard on developing the person centred care planning system and risk assessments. The requirements made at the last inspection regarding the care plans, risk assessments and health action plans had been met. The home had further improved the facilities available to the residents by installing en-suite facilities consisting of toilet, wash hand basin and shower units in three of the four bedrooms. There was evidence on the residents’ files that discussions such as whether they wanted keys to their bedrooms had been undertaken and a copy of the service user guide was available on the files. Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 6 There was a refurbishment programme for the home in place. 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. The summary of this inspection report can be made available in other formats on request. Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): A judgement could not be made on these standards as no new residents had been admitted to the home. EVIDENCE: The admission process was not assessed at this inspection as no new residents had been admitted since the last inspection. Any requirements made at the last inspection regarding these standards will be carried for to the next inspection. Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning and risk assessment in the home ensured that the needs of residents were met safely and in the way the residents wanted. EVIDENCE: On the day of the inspection the inspector noted that the care plans were stored in a bookcase in the dining room. This did not comply with the requirements of the data protection act and issues of confidentiality could not be guaranteed to the residents. The home had made some very good progress on the person centred care plans. The residents’ files contained a section on ‘This is me’, which gave some very good background information and identified areas where risk assessments were needed and where they could be found in the file. The files detailed their likes and dislikes and a working care plan detailed how the residents liked to be assisted. There were some very good sections included in the files that recorded achievements and evaluation for areas such as medical needs but these had Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 10 lapsed over the past six weeks. Some of the sections such as ‘ things I would like to do with my life and how I am going to achieve them’ needed to be reviewed and targets reset. A health action plan had been set up for the residents and this was pleasing to see. There was evidence in the plans that issues such as whether the resident wanted a key to their bedroom and the home had been discussed with them. Risk assessments were in place for the residents’ individual needs. Some residents were able to go out alone and use public transport whilst others needed to have specific assistance with organising the transport. One of the residents was spoken with in length and he was aware that the person centred plan was in place. Other residents were able to make decisions about going out and receiving health care, for example, one resident came home and stated how he needed to go and see the dentist and how it was going to be achieved. Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents lead fulfilled lives according to their needs and wishes. Residents are encouraged to take responsibility where they can and contact with relatives is encouraged by the home. EVIDENCE: There was ample evidence that the residents were enabled to undertake activities that allowed for personal development. One of the residents told the inspector how he was being helped to read and write. He knew the activities that were available in the home and made it clear which ones he wanted to take part in and which he did not. He had wanted to go to a day centre but he was not allowed to smoke there. One of the residents helped in clearing up at the table whilst another enjoyed assisted staff in making toast at breakfast time and sometimes assisting with making the sandwiches and emptying the dishwasher. Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 12 Some residents had a very structured day and went out to college or visited relatives. They went out regularly to the pub, the cinema or on shopping trips with the manager. Three of the residents liked to go bowling but the other didn’t and a member of staff stayed in the home when he didn’t go. Activities such as watching DVD’s or listening to music or reading were available in the home. Contact with families was encouraged. During the inspection one of the residents had a family visitor who stated they were happy with the care provided at the home. They felt that the resident would speak up if he were not happy with something. Another resident had been on a holiday to Ireland to visit relatives and stated his long-term wish was to move there. Residents regularly went out shopping for the household shopping and residents stated that they were happy with the food they had. There were food records and a four-week menu that showed that the meals were varied and met the needs of the residents. The staff needed to ensure that food records were completed every day. Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents were provided with personal care in a sensitive manner and their health care needs were met. Some improvements were needed to the management of medicines in the home to ensure it was safe. EVIDENCE: Residents were supported to take responsibility for personal care but were assisted where this was required. Residents health care needs were followed up and appointments made with the appropriate individuals. Since the last inspection health care action plans had been put in place. At the time of this inspection all but one of the residents had access to en-suite facilities for washing and showering. The home used a weekly monitored dosage system for the management of medicines. The new medication period started on the day of the inspection. The medicines were delivered to the home during the morning. Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 14 Whilst auditing the medicines it was noted that the morning medicines had been administered to the residents from the previous weeks dosage system however, the staff were not able to sign that this had happened as the new Medication Administration Charts (MAR) had not arrived. The manager needed to liaise with the pharmacist to ensure that the medicines and MAR charts were received at least a day early so that they could be checked against prescriptions. The inspector was informed that the manager was aware of the difficulties and trying to come to a solution. The medicines were stored in a locked, wooden cabinet and on auditing the medicines the inspector found that there were stocks of 6 tubes of Metronidazole cream dating as far back as 8.5.06 that needed to be returned to the pharmacist. In addition there were two open tubes of this cream dated 26.5.06 and 27.7.06. It was evident that the creams were not being applied as required or the cream was no longer required. In addition there was other tablets and eye drops that needed to be returned to the pharmacist. There were four Diazepam Rectubes in the home dated 17.11.05 but these were not recorded anywhere. The inspector was informed that the manager could use them in an emergency. If these are to be kept in the home these needed to be carried over on the MAR charts. There were Ibrufen tablets of two different strengths that were unaccounted for on the MAR charts. There were no copies of the prescriptions available at the time of the inspection and the medicines were not being booked in. There were no residents who were able to manage their own medicines. The inspector was told that the staff had had basic training on using administering the medicines. There were controlled medicines in the home and no medicines fridge was currently required. Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were policies in place however the procedures in the home did not always safeguard the residents. EVIDENCE: There were complaints and adult protection policies in place at the time of the last inspection. These were not inspected on this occasion. One of the resident’s said he would know who to tell if he was unhappy and a relative stated that she felt he would be able to communicate his views. Observations between the staff and residents indicated that there was good communication between them. Some improvements needed to be made to the recruitment procedures to ensure that the residents were safeguarded and some changes needed to be made to the records regarding residents’ monies. It could not be determined whether all staff had had adult protection training. Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is kept clean and tidy whilst improvements are made to the home and once decorated and refurnished a good quality environment will be available to the residents. EVIDENCE: At the time of the inspection building work was going on to the extension at the side of the home however this was not impacting negatively on the residents at the home. There was a lounge/dining room that was comfortably furnished with pleasant furnishings. At the end of the dining area there were patio doors leading to the rear garden. The patio area was not accessible to the residents at the time of the inspection as the laundry equipment had been moved there whilst the building works were in progress. The sleeping in member of staff was using the lounge whilst the building works were completed. Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 17 The residents’ bedrooms were comfortably furnished and personalised with their personal belongings. Since the last inspection all but one of the bedrooms had had an en-suite shower facility fitted further promoting privacy and independence. There was an additional bath and separate toilet on the first floor. The resident without an en-suite facility generally used these. The residents had got the additional equipment that they required for example, a tripod and wheelchair. The home was centrally heated and the majority of radiators had been guarded. One of the radiators in the passageway was found to be very hot and needed to be guarded. The carpet in one bedroom was lifting and posed a potential tripping hazard. Even though there were plans for the carpets to be replaced this carpet needed to be taped down as an interim measure. There was a refurbishment plan in place that indicated that decorating and carpet changes would be achieved by May 2007. The home was clean and hygienic. Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The recruitment procedure needed to be more robust and staff needed to have regular updates on their training. EVIDENCE: There was always one member of staff on duty in the home. There was a member of staff allocated specifically to domestic tasks. Additional staff were made available when a resident did not want to get involved in the activities organised. The staffing levels will need to be adjusted when the registered numbers in the home are increased. Three staff files were sampled. The three files evidenced that the staff had undertaken some training. The care staff were NVQ trained and had undertaken mandatory training in food hygiene, fire awareness, safe handling in medicines and infection control, although some of their training had been undertaken elsewhere. The manager needed to ensure that all staff undertook refresher courses as required. A training matrix needed to be set up to ensure this was monitored and actioned as required. The staff spoken with were found to be knowledgeable about the residents needs and how to manage any presenting behaviours. The small staff team Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 19 enabled support and supervision of the staff to be undertaken on an informal way. Two of the staff files evidenced that induction had been started but not completed by the two staff. One of the files did not have evidence that a CRB or POVA check had been applied for and the other file had a CRB from another employer. These checks were not transferable. These two files did not have two references dated and addressed to the employer. The third file was of a member of staff that had been employed at the home for some time. Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40 and 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Some aspects of the management of health and safety in the needed to be improved but the care given to residents was good. EVIDENCE: The observations of interactions between staff, residents and visitors on the day of the inspection showed that the routines were organised to meet with the residents’ individual needs. The home was generally well managed and able to run in the absence of the manager. The inspector was unable to determine how the home was implementing a quality assurance system in the home due to the absence of the manager, however this had been recommendation from the last inspection. This recommendation has been made a requirement at this inspection. Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 21 On checking of the regular fire alarm and emergency lighting tests it was found that these had not been recorded as having been carried out since 1.8.06. The fire yearly electrical wiring test had been last undertaken on 2.8.05. The portable appliance checks were carried out in September 2005 and needed to be repeated. The fire risk assessment was not seen at the time of the inspection and evidence that it has been updated, in light of the building works in place, needed to be forwarded to the CSCI. As stated earlier, there were some building works in progress at the time of the inspection. The gas boiler was sited in the new extension but the gas board had left a warning on it. Discussions with the builder present at the home indicated that this was because the boiler had not yet been moved to an external wall so that the flue could vent any dangerous gases to the outside. The windows and doors had not yet been put in place and so there was no danger of any build up of gases. When the building work had progressed the boiler would be moved to the external wall. The manager needed to ensure that there was a risk assessment in place and ensure that the boiler was moved as soon as practicable. Some residents were being assisted with managing their monies. The manager needed to ensure that there were two signatures for all entries where a transaction had taken place and it would assist in auditing procedures if the receipts were numbered. For one of the residents the records showed a transaction of £16.04 however on further examination of the receipts this was in fact the change as the expenditure was for £3.96. The resident needed to be reimbursed the correct amount of money. There was a system of charging the residents a set amount of money for each trip when going out in the car. Each resident was charged the same amount. Whilst the inspector can appreciate that there is a benefit to the residents of having access to the vehicle the manager must ensure that the real cost of the journey is shared equally between those going on the trip rather than charging a blanket amount irrespective of the length of the journey. It was not clear if there was any financial input from the home to assist in providing the residents with activities. Some of the travel costs could be recouped from the activities budget. Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 2 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 2 X 1 2 X 1 2 Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 23 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 YA1 Regulation 4 (1c)Sch 1 Requirement The statement of purpose must be updated to reflect the changes made in the home. Timescale for action 01/02/07 2. YA6 12(1)(a) 15 13(4a-c) 01/01/07 Care plans and risk assessments must be reviewed at least every six months. Reviews should be recorded in writing, indicating who takes part and how decisions are made. (Previous timescales of 31/08/05 and 01/01/06 not met.) The manager must ensure 01/01/07 that the different sections of the person centred plan are reviewed and updated on a monthly basis or earlier if required. Food records must be 01/12/06 completed every day. All medicines must be 01/01/07 checked against the prescriptions and the amounts received entered on the MAR charts. 3. YA6 15(2)(c) 4. 5. YA17 YA20 17(2) Sch4(13) 13(2) Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 24 The manager must ensure that the medicines and MAR charts are received in sufficient time to enable the staff to comply with the medicines procedures. All excess medicines must be returned to the pharmacist at the end of the medication period. There must be a record of all medicines in the home. Creams must be applied in accordance with the doctor’s instructions. Copies of prescriptions must be kept in the home. 6. YA20 13(2) Staff administering medicines must undertake accredited training in the safe handling of medicines. All staff must receive adult protection training. The radiator in the corridor was found to be too hot and must be guarded. The bedroom carpet identified during the inspection must be made safe. The manager must ensure the carpets are replaced and the re-decoration of the home is completed. A risk assessment must be put in place to ensure that residents accessing the garden are safe whilst the DS0000017128.V317427.R01.S.doc 01/04/07 7. 8. YA23 YA24 13(6) 13(4)(c) 01/03/07 01/01/07 9. YA24 13(4)(c) 01/12/06 10. YA24 23(2)(b) 01/06/07 11. YA28 13(4)(c) 01/12/06 Poppy Lodge Version 5.2 Page 25 laundry equipment is on the patio. 12. YA29 23(2) A maintenance contract must be put in place to ensure the specialist equipment in the home is checked at least annually. Previous timescale given 01/01/06. Compliance not assessed at this inspection and the requirement has been brought forward. The manager must ensure that CRB, POVA and references are sought and received prior to an individual is employed. 01/02/07 13. YA34 Sch 2 01/12/06 14. YA34 18(1)(a) 15. YA35 12(1)(a) 18(1)(a) Staff must complete 01/12/06 induction in line with Skills for Care within 12 weeks of commencing employment. Submit a detailed staff 01/01/07 training and development assessment to CSCI, as indicated in the main body of this report. (Previous timescales of 30/09/05 and 01/01/06 not met.) Develop and implement a 01/04/07 Quality Assurance system for the home based on the views of the residents. The manager must ensure 01/12/06 that residents are not charged at a standard rate for journeys in the car but are calculated on the basis of the actual cost and number of individuals using the service. There must be two signatures for all 16. YA39 24(1) 17. YA40 YA23 12(1)(a) Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 26 18. YA41 Data Protection Act 1998 13(4a-c) 19. YA42 expenditures made on behalf of the residents. The manager must ensure 01/12/06 that records are stored in compliance with the Data Protection Act 1998. Send CSCI a copy of the fire 01/01/07 risk assessment. This should be signed and dated at the time of the review. (Previous timescale of 01/01/06 not met.) The premises risk assessment must include the potential risk due to the current position of the gas boiler. 20. YA42 23(4)(c)(v) The fire alarm must be tested and records maintained on a weekly basis. The emergency lighting must be tested and records maintained on a monthly basis. 01/12/06 21. YA42 23(2)(c) Evidence that the portable appliances have been tested must be forwarded to the CSCI. Evidence that the fire alarm system has been serviced must be forwarded to the CSCI. 01/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 27 No. 1. Refer to Standard YA5 Good Practice Recommendations Provide facility in residents’ contracts for countersignature by relative or other independent person, where resident is unable to sign. Outstanding from the previous inspection Develop and implement a Quality Assurance system for the home. 4. YA39 Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Poppy Lodge DS0000017128.V317427.R01.S.doc Version 5.2 Page 29 - 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. 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