Inspection on 10/05/05 for The Poplars

This inspection was carried out on 10th May 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Poplars 25/04/07

The Poplars 07/11/05

The Poplars 27/01/05

The Poplars 24/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 The Poplars 1 Station Road Whitwell Derbyshire S80 4TD Lead Inspector Bridgette Hill Unannounced 10 May 2005 09:30 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. The Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Poplars Address 1 Station Road, Whitwell, Derbyshire, S80 4TD 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) (01909) 722244 Faxes are circulated from head office 01909 475 162 RAINES@rnorsaca.freeserve.co.uk Nottingham Regional Society for Autistic Children and Adults Mr Kevin Michael Pakenham Care Home 5 Category(ies) of Learning disability (5) registration, with number of places The Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 27th January 2005 Brief Description of the Service: The Poplars care home is situated in a quiet residential cul de sac near the centre of Whitwell. The home is a brick built bungalow in a residential area with a secure private garden. All residents are accommodated in single rooms. The home is registered as a care home to provide personal care for up to 5 adults with learning disabilities aged 18 to 65 years. The home specialises in providing care for adults with Autism. The Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced one. The manager was not on duty at this visit and staff could not access some records. Two families were contacted after the inspection to ascertain their experience and views of the service being received by their relatives. Various records including care planning records were examined the findings are recorded in the body of this report. What the service does well: What has improved since the last inspection? What they could do better: The garden needs attention as it is untidy and overgrown. Care plans require development to include how service users assessed needs are being met regarding social needs and the development of independent living skills. The Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 Page 6 The administering of service users monies was inaccurate and procedures must be improved to ensure staff are vigilant with recording of transactions. 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 Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 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 The Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 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) 1,2,3,4,5 The Service User Guide was not being made available to service users or families. Service users are introduced and accepted for placement after wide consultation and assessment has taken place this ensures that service users needs can be met prior to admission taking place EVIDENCE: A Statement of purpose was available in the staff office which contained all the relevant information. Staff on duty could not locate a Service User Guide. This is an outstanding requirement from previous inspections. Terms and conditions of residency contracts were written in simple language and had been signed by the service user. Review information for service users was available which indicated multi agency assessment and consultation with families occurred prior to placements being offered. Service users were frequently known to staff within the home through day service attendance and the close links that were in place between the Poplars and sister homes in the organisation. Trial periods were offered and introductions tailored to service users needs. The Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9 Care plans varied in the detail recorded. They were not sufficiently detailed regarding social and independent living skills to demonstrate that the care being given actually met the individual service users assessed needs. EVIDENCE: Care plans were in place for all service users, two were selected to be examined. Care plans varied in the detail recorded on how care was to be delivered. Some were very specific in certain areas such as how to communicate with service users. Whilst it was evident that service users had many opportunities to develop skills and participate in leisure activities care plans did not reflect this. One file did not record the admission date to Poplars. Care files contained photographs of the service user. Care files included comprehensive risk assessments and the action plans to limit risks. The Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 Page 10 Review information was held in care files and families spoken to said they were involved in the review process. As many service users have significant communication and perception difficulties their ability to participate in the care planning process is accepted as being limited. Care files contained information on service users likes, dislikes and preferences. All service users required assistance with finances. The Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 There was an excellent structure to the provision of activities both inside and outside the home but these were not supported by documentation to ensure they were meeting service users assessed needs and progress was not recorded. Families of service users are involved in their relatives care and kept informed at al times. Excellent communication was evident with families and many positive comments were received. EVIDENCE: Included in the fees are day services provided outside of the home at facilities ran by the Provider. Some of these are aimed at promoting skills such as food preparation. Other day services are more leisure based such as swimming, walking and using relaxation rooms. Residents get many opportunities to go out accompanied by staff and participate in the running of the home by for example going shopping. These The Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 Page 12 were recorded in care records and families also spoke positively of the social activities offered. Staff work alongside residents on an allocated day to participate in housekeeping tasks. Whilst choices are promoted this is done in a sensitive way to help alleviate the anxiety choice and change can cause in residents with Autism. A range of activities were offered in the home, such as bowling, to local parks, takeaway and video nights. Social nights and occasions were also organised with sister homes in the organisation and friendships established with other service users. Some service users had recently been away on a holiday to Snowdonia. Care planning documents sometimes contained a schedule of activities that service users were involved in but there was not an individualised social plan in place for each service user based on assessed needs. This has been identified on previous visits. Families spoken with knew the key worker allocated to their relative and reported regular contact, sometimes daily with staff at the home. Relatives said they felt they were kept informed and were consulted regarding care decisions. Some service users spent time on leave with their families on a regular basis. Families spoken to said they were always made welcome on visits to the home. The Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 Service users healthcare were being met this included consultations for identified problems and routine health screening appointments. EVIDENCE: Community healthcare facilities were widely used with visiting healthcare professionals used only in emergencies. Healthcare needs were considered to be met through information available in care files and discussions held with parents of service users. It was apparent from files and discussions with staff that some service users needs are changing with age. There was information to confirm relevant healthcare professionals were consulted such as speech and language therapists and occupational therapists. One service user had been assessed and needs identified with regard adaptation of bathing facility; this had not yet been addressed. An audit trail of medications was not possible as there were no records of medication returns available. Topical preparations were dated on opening. Where medication administration records had been handwritten they had not The Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 Page 14 always been signed or verified by a second staff member that the instructions were correct. An appropriate drug reference book was available. The Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 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 Staff had received sufficient training and had appropriate knowledge of procedures relating to the protection of vulnerable adults to ensure appropriate actions would be taken if abuse were suspected. Staff were not robustly implementing the system in place for recording service users monies. The potential for mistakes and inaccuracies was therefore evident. EVIDENCE: No complaints had been received at the home or by Commission for Social Care Inspection since the last inspection. The complaints procedure was displayed in the entrance hall and contained the Commission for Social Care Inspection address. This was not in a format suitable for service users and the recommendation that this be included in a picture format in the Service User Guide remains listed. Staff spoken to had received Protection of vulnerable adults training and knew what to do should they have any concerns. This was supported by appropriate policies and procedures. Staff spoken knew about the whistle blowing procedure. Each service user had their own bank account and small amount of money held securely in the home for daily use. A sample of service users monies was examined. These indicated that one service user had an ‘I owe you’ note from another service user in their money. As all service users required help with finances it is unlikely that they able to give consent for this. The balance of The Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 Page 16 monies available was not accurate to the actual amount of money in purses/wallets. Receipts were retained for purchases The Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 Page 17 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) 24,25,26,28,29,30 The home provides care for service users in a homely environment. All service users bedrooms are individual and indicate service users are given choices and encouraged to develop personal tastes. Ongoing consideration of the environment must be considered with prompt actions being taken to ensure service users needs are able to be met. EVIDENCE: The bedrooms were individually decorated in styles which reflected the preferences of the residents. Where a new resident had been admitted the furniture the service user had chosen in a previous home in the organisation was relocated to the Poplars. The home provides a domestic type environment for residents with an open plan lounge/diner. New dining chairs had not yet been provided as recommended previously and were of varying designs and colours. Families spoken to liked the domestic and homely accommodation offered. The garden was overgrown and was in need of attention. The Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 Page 18 All parts of the home were found to be clean and tidy. Chemical cleansers were securely stored. Discussions were held with staff on duty regarding the siteing of laundry through the kitchen area as service users needs were increasing regarding physical frailty. Staff spoken with said that plans are being considered to address the problem of laundry being carried through the kitchen area. The increasing physical needs of service users was being considered and bathing aids and adaptations were assessed as being required. Staff spoken said that plans for refurbishment of bathrooms were being considered. One service user did have a special mattress in place. The Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 Page 19 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) 33,34 Staff personnel files were mainly complete with all the required documentation; a few deficits were still evident. The staff team at Poplars appears to be a committed one who are able to meet service user needs. EVIDENCE: The staff team at Poplars is a stable one with few changes occurring. Where there are changes these are mainly promotions within the same organisation. Staff spoken to demonstrated a good knowledge of the residents being cared for. All care staff undertake catering and domestic duties as part of their role, some of these tasks are working alongside service users to promote domestic skills. A sample of staff personnel files were examined. These were well organised. One file did not contain a second reference. One file did not have a proof of identity, attempts had been made by the Provider to secure this as a letter had been written to the employee requesting they supply this. This remains listed as an outstanding requirement. The Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 Page 20 There are 6 care staff employed at the home, 3 of these hold at least an NVQ (National Vocational Qualification) level 2 in care meeting the 50 requirement. Staff on duty knew about the General Social Care Council Code of Conduct and had a copy to hand. The Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 Page 21 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) 41,43 Service user records were not complete and information required was not immediately available. EVIDENCE: A certificate is displayed confirming the Manager holds a relevant managerial qualification. The public liability certificate was displayed and was in date. Records for establishing financial liability were not examined. Service user records are held securely in an office. Not all information was up to date in service users files such as GP and date of admission. The Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 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 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 x 2 3 3 Standard No 11 12 13 14 15 16 17 3 3 4 4 4 x x Standard No 31 32 33 34 35 36 Score x x 3 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Poplars Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x x x 3 x 3 C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 Page 23 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 YA1 Regulation 5 Requirement The Service User Guide must include all aspects described in the National Minimum Standard 1.2 Timescale for action Old timescale 31.8.04 new timescale 30.7.05 Old timescale 30.3.05 new timescale 30.7.05 30.7.05 Old timescale 30.3.05 new timescale 30.7.05 30.7.05 30.7.05 30.8.05 2. YA7 15 Care must be taken to ensure that all aspects of assessed needs are covered in sufficient detail in care plans Care files must contain all aspects as detailed Schedule 3 If the Medication Administration Record is handwritten or altered by a member of staff this must be signed and dated by them. This must then be checked, signed and dated by a second member of staff. Where medications are returned or disposed of a record must be kept. An accurate record of financial transactions must be recorded The garden must be tidied and made good for service users to enjoy 3. 4. YA7 YA37 YA20 Schedule 3 13,17 Schedule 3 5. 6. 7. YA20 YA23 YA28 13,17 Schedule 3 Schedule 4 16 23 The Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 Page 24 8. YA34 19 Schedule 2 Staff recruitment files must contain all aspects of Schedule 2, this must include proof of identity Old timescale 31.8.04 new timescale 30.8.05 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. Refer to Standard YA1 Good Practice Recommendations The picture format Service User Guide and information pack should be developed to include residents views and information on how to make a complaint The Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road Derby. DE1 3QT 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 The Poplars C52 C02 S20076 The Poplars V225886 100505 Stage 4.doc Version 1.30 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. 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