Inspection on 10/05/06 for The Poplars

This inspection was carried out on 10th May 2006.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Poplars 17/05/07

The Poplars 21/10/05

The Poplars 02/06/05

The Poplars 12/01/05

The Poplars 06/07/04

The Poplars 25/03/04

Similar services:

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

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

CARE HOME ADULTS 18-65 Poplars, The 889 Chester Road Erdington Birmingham B24 0BS Lead Inspector Susan Scully Unannounced Inspection 10th May 2006 09:00 Poplars, The DS0000033636.V288932.R01.S.doc Version 5.1 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, The DS0000033636.V288932.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Poplars, The DS0000033636.V288932.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Poplars, The Address 889 Chester Road Erdington Birmingham B24 0BS 0121 373 0288 0121 386 2460 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) Social Care and Health Ms Munira Rahemtulla Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Poplars, The DS0000033636.V288932.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That the home is registered to accommodate 9 adults under the age of 65 who are in need of long-term personal care for reasons of learning disability. Currently residing people who are over 65 may continue to be accommodated provided their needs can be met appropriately. The minimum staffing levels for 12 service users on weekdays when day care is off site: 7.00am - 9.00am 3 care assistants, 1 of whom is designated shift leader 9.00am - 4.00pm 3 care assistants, 1 of whom is designated shift leader 4.00pm - 10.00pm 4 care assistants, 1 of whom is designated shift leader 10.00pm - 7.00am 2 care assistants (both awake) At weekends and period without off-site day care: 7.00am - 10.00pm 4 care assistants 10.00pm - 7.00am - 2 care assistants (both awake) Window frames that are in poor condition must be repaired or replaced by end of September 2004. Double-glazing and/or additional heating must be installed in the conservatory in house 837 to ensure temperature is maintained at 21oC by end April 2004 By end September 2004 plans are agreed with the CSCI with stated timescales for the future re-provision of this service to ensure standards commensurate with fitness for purpose for the needs of the client group. Re-provision to be completed by 1st April 2005. 21st October 2005 4. 5. 6. Date of last inspection Brief Description of the Service: The Poplars is a local Authority home offering care for up to 12 adults with a learning disability. Accommodation is arranged in three houses. The Poplars has its own large frontage and rear gardens and is in an established residential area of Birmingham. The houses blend in well with other houses in the area. There are a number of local bus routes, local shops, and a railway station near by. The home is well located to access Erdington and Sutton Coldfield. The home has a total of five lounges/quite rooms. The main dining room is large and most residents use this room for their meals. The bedrooms at the home vary in size, but are all single rooms. The home has six bathrooms and seven toilets. The main house dose not have a toilet located on the ground floor. Poplars, The DS0000033636.V288932.R01.S.doc Version 5.1 Page 5 Access between the three houses is through a series of hallways and staircases and is not ideal. Poplars, The DS0000033636.V288932.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit took place over one day by two inspectors. Records were sampled pertaining to staff, training, resident’s Healthcare and Health and Safety. Comments from staff and Healthcare Professionals have been incorporated in to the report. The inspectors would like to thank residents and staff for their contributions made to determine the outcome for residents who use the service. Conditions number 4 & 5 above have been met, and will be removed following this key inspection. Condition number 6 is partially met, and will be replaced with ‘Reprovision plans to progress at a pace, which is acceptable to CSCI to allow continuation of registration’. What the service does well: What has improved since the last inspection? What they could do better: Health Action plans for resident have commenced; however these needs to be more personalised to the individual. Although part of the building has been decorated, the building itself is not fit for purpose. There are plans to re-develop this service and Birmingham city council are continuing to liaison with CSCI. Please contact the provider for advice of actions taken in response to this Poplars, The DS0000033636.V288932.R01.S.doc Version 5.1 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Poplars, The DS0000033636.V288932.R01.S.doc Version 5.1 Page 8 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 Poplars, The DS0000033636.V288932.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 2 This service in being re-developed. There are no plans to admit residents in the foreseeable future. There has been no development in the production of a format to use in the admission process. EVIDENCE: No progress has been made with the introduction of a format to enable a robust admission procedure. The manager said “ There will be no admissions in the foreseeable future’’. “Those residents who have chosen to move from the Poplars have done so’’. “There will be no new admission to replace those who have left’’. Poplars, The DS0000033636.V288932.R01.S.doc Version 5.1 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 the following standard(s): 6, 7, 9 Residents are encouraged to be involved in decisions about their life’s and where they live and how they live. Care plans give adequate information to staff to meet the gaols and objective of each individual. Risks are monitored and reviewed. EVIDENCE: Care plans sampled showed a significant improvement and contained information provided by the residents. Goals were identified and objective monitored on a monthly basis. When residents did not meet their identified objectives action was taken with the resident to identify a way forward. All information was recorded. Risk assessments were completed and showed how risks were managed. The manager said, “Those residents who are competent to judge the risk to themselves are encouraged to make their own decisions within a risk assessed framework’’. “Each month I complete an audit of the care plans and when I identified an objective is not met I discuss this with the resident to assess if the objective is achievable if not why not’’. Poplars, The DS0000033636.V288932.R01.S.doc Version 5.1 Page 11 Each resident makes their own decisions and this is recorded in the individual care plan’’. Regular meetings are held with the residents to ensure they are envolved in decisions about the running of the Poplars. Poplars, The DS0000033636.V288932.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 15, 16, 17 Residents have freedom of choice with activities. Residents are supported by staff when required. Menus sampled showed residents could choose what they wanted to eat. Meal times are flexible. EVIDENCE: Resident go out regularly to the day centre, shops and clubs either with family or friends. The venue is their choice. Residents did not want to speak with the inspectors during this visit. However, one resident said the food was good now, and it was ok living at the Poplars. One resident was going out, the other was watching a video. Other residents were out or attending the day centre. Each resident has an active plan that includes day trips, shopping, eating out, colleges, and outings with different clubs. The manager said, “Families and friend are encouraged to participate in activies as much as possible’’. Poplars, The DS0000033636.V288932.R01.S.doc Version 5.1 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 the following standard(s): 18, 19, 20 Care plans demonstrated adequate measures are taken to ensure residents health and welfare is maintained. The Administration and Recording of medication records showed some errors that the manager must address. EVIDENCE: The care plans and assessment of residents identify personal care, medical, appointments regular visits to dentist and opticians. Healthcare is monitored and appropriate action taken. The manager showed the inspectors the new Health Action plans that will be implemented after full discussion with the residents has taken place. Further information about the person should be included in the Health Action plans for them to be personal to the individual. Medication records were sampled. Some omissions were seen; records could not be audited as MAR Charts (Medication Administration Records) were not filled in correctly for PRN medication (As required medication). For example Paratecamol did not show on the MAR Chart how many were administered if the prescription stated one or two to be given as requires. The manager said no homely remedies are stored at the home. Discussions were held surrounding the possibility of contacting residents GPs for advice on homely remedies being kept at the home. Poplars, The DS0000033636.V288932.R01.S.doc Version 5.1 Page 14 The manager must ensure when staff administer medication the correct information is recorded on the MAR Charts. (Medication Administration Record) The recording pertaining to medication received and return was adequate. All medicines were stored securely and appropriately. Poplars, The DS0000033636.V288932.R01.S.doc Version 5.1 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 the following standard(s): 22, 23 Arrangements are in place to minimise risks so that the safety and welfare of residents are promoted. Polices and Procedures ensure residents are safeguarded from abuse or harm. EVIDENCE: Risk assessments for individual residents and the environment are carried out so that the risk of a potential accident is reduced. Risk assessments are completed, monitored, and reviewed on a regaul basis. Discussions were held with the manager to ensure once a risk had been identified and resolved this information is then recorded in individual care plans. All staff spoken to had a full understanding of potential indicators of abuse and what to do if they became aware of an allegation of abuse. They confirmed they had recently received training in Adult Protection. Poplars, The DS0000033636.V288932.R01.S.doc Version 5.1 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 the following standard(s): 24, 30 This service is being re-developed. The improvements in the appearance of the building and in certain areas have contributed to the Poplars homely environment. Further work is ongoing and is part of the identified re development of this service. EVIDENCE: The requirements from the previous visit pertaining to the environment have commenced and include the rear of the building being painted while the inspectors were in attendance. Bathrooms and toilets had been redecorated. A maintenance programme had been completed. Other areas that had been identified such as kitchen cupboards and worktops had been replaced. During the last inspection concerns about the cleanliness of the kitchen was identified. It was pleasing to see measures had been put in place to ensure a schedule of cleaning was maintained on a weekly basis. The Poplars was clean and fresh. Poplars, The DS0000033636.V288932.R01.S.doc Version 5.1 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Most staff has received the relevant training in mandatory areas. The locations of recruitment records remain an issue that has not been resolved and measure must be taken to ensure copies of records pertaining to recruitment are available for inspection. Supervision is completed on a regular basis. Supervision must also be applicable to any member of staff who is involved in the residents care to include placements from other establishments. EVIDENCE: Each staff member had an individual training profile that clearly showed who had received training in mandatory areas. Care staff spoken to said they felt their training needs were being met. Staff said they had an insight in to challenging behaviour and were not alarmed by unpredictable behaviour that may occur. Records pertaining to recruitment are held at head office, however the manager had made a copy of a recent employees application from and relevant details. Only one reference for this employee was available. CRB disclosures were not kept secure which meant a number of staff had access to personal information. The manager agreed to ensure this information was kept in a separate store so only she had access to the CRB Disclosure. The manager must ensure that two references are obtained for all staff. Other issues discussed were a placement of an employee. There were no records available. The manager said she did not know the details of this employee. Poplars, The DS0000033636.V288932.R01.S.doc Version 5.1 Page 18 The manager was not aware of the implications this would place both on the member of staff and the residents. No risk assessment had been completed. The manager was advised to speak with her Team Manager for more information. Supervision is completed regularly, however no supervision had been completed for the person who was on placement. Induction for the most recently employee was not available in the file sampled. In order to fully protect residents and staff it imperative the manager has the relevant information available for all care staff. Locations of recruitment records remain an issue that has not been resolved. Measures must be taken to ensure records are available for inspection until an agreement with CSCI has been reached. Poplars, The DS0000033636.V288932.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 This service has improved significantly since the last inspection. Care plans and record keeping is of a good standard. Health Action Plans for residents require further development for a more personalised focus on individuality. EVIDENCE: This service is being re-developed. The manager and staff have worked with residents and their family to ensure there is as little disruption as possible. Some residents have chosen to move into community to accommodations of their choice. Residents have moved with the assistance of family, friends and Social Workers. Residents who have chosen to remain at the Poplars have the support they require. The manager said “resident have specifically asked to remain at the Poplars and this is part of their Personal Centred Planning’’. “The occupancy of the Poplars has reduced since the last inspection. Health and Safety Records such as Fire Safety, Fire Drills, Fire Training and the servicing of equipment were up to date. Poplars, The DS0000033636.V288932.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 2 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Poplars, The DS0000033636.V288932.R01.S.doc Version 5.1 Page 21 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 YA2 Regulation 14(1)(a, b, c,) Requirement Timescale for action 01/06/06 2 YA5 5(1)(c) 3 YA20 13(2) 4 YA24 23(2)(c) A complete needs assessment must be completed for all new admissions. Previous time scale 01/03/05 Non Compliance. All residents must have a 01/06/06 contract of terms and condition of residency. Previous time scale 01/03/05 Not assessed. The registered manager and 01/06/06 staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the home’s policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. A maintenance programme 01/06/06 must be developed for the ongoing repairs of the building giving time scales for completion. Previous time scale 01/03/05 Partly met. Version 5.1 Page 22 Poplars, The DS0000033636.V288932.R01.S.doc 5 YA34 17(2)(b) Sch 4 6 YA36 18(2) Records pertaining to the recruitment of staff must be available for inspection in the home. Previous time scale 01/03/05 Compliance not met. All staff must be appropriately supervised including work placements. 01/06/06 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Poplars, The DS0000033636.V288932.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Birmingham 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. Extracts may not be used or reproduced without the express permission of CSCI Poplars, The DS0000033636.V288932.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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