Inspection on 13/03/07 for The Poplars

This inspection was carried out on 13th March 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Poplars 01/03/06

The Poplars 19/10/05

The Poplars 01/02/05

The Poplars 15/11/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE The Poplars 4 Glen Eyre Way Bassett Southampton Hampshire SO16 3GD Lead Inspector Chris Woolf Key Unannounced Inspection 13th March 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Poplars Address 4 Glen Eyre Way Bassett Southampton Hampshire SO16 3GD 023 8067 7831 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 K Cox Miss J Cox Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15), Physical disability over 65 years of age (4) of places The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Not more than 4 service users in the category PD(E) are to be accommodated at any one time 1st March 2006 Date of last inspection Brief Description of the Service: The Poplars is registered under Penhaligon Limited and is located in Bassett, a residential district of Southampton close to local amenities. The Poplars now provides accommodation for 14 older persons in 10 single rooms and 2 double bedrooms, all of which have en-suite toilet and washbasin and most with shower facilities. The home has a stair lift to access the upstairs level. There is a parking area at the front of the house and a pleasant garden at the rear. The registered manager is Miss Jodie Cox who is also one of the Registered Persons in Control. The current fees for the service at the time of the visit range from £400 to £510 per week. Information on the Home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. Currently there is no e-mail address available for the home. The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information in this report has been gained from a pre-inspection questionnaire completed by the home; surveys received from 1 resident and 1 visitor; and a visit to the home lasting 6 hours. The inspection visit included speaking with the majority of residents, 3 visitors (including 2 visiting professionals), staff on duty, and the deputy manager; observation of a mealtime, general practices in the home, and the interaction between residents, staff, and visitors; and inspection of a variety of records. What the service does well: What has improved since the last inspection? Since the last inspection there have been various environmental improvements including new carpet in the lounges and hallways, 2 bedrooms have been redecorated and carpeted and 3 have been fitted with new curtains, and two new windows have been fitted. In addition the front car park has had new tarmac laid, and the damp course in some bedrooms has been replaced. The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 6 There has been additional staff training including training in adult protection and dementia. 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. The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, & 5. Standard 6 is not applicable in this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can be confident that they will receive sufficient information about the home; that their needs will be assessed; that they can have a trial visit if they wish; and that the home will be confident of meeting their needs before they are admitted to the home EVIDENCE: Prospective residents are given a copy of the statement of purpose and a copy is also placed in all bedrooms. All residents are issued with a contract of their terms and conditions with the home. The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 9 An assessment of prospective residents needs takes place in the venue of their choice. Occasionally the home accepts emergency admissions and in such instances information is obtained from the care manager involved, however such incidences are very rare. Pre admission assessments are comprehensive, and sufficient details on health, social and cultural needs to enable the home to be confident that they can meet the resident’s needs prior to admission. When there are vacancies the home will accept residents for respite care and the first month of any stay is classed as a trial visit. Service users comments included, “I came for a 2 week stay, then came back”, and “I cant remember whether anyone came to see me or not”. This home does not offer the facility of intermediate care The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individualised care plans are detailed, and are regularly reviewed and agreed by the resident. Health care needs are met by the home in conjunction with a multi-disciplinary health care team. The home’s medication procedures are robust. Residents can be confident that they will be treated with respect and have their privacy protected. EVIDENCE: A comprehensive individual care plan is produced for each service user based on the information gained during the pre admission assessment. They also include details of recreational and cultural needs, and appropriate risk assessments. Any contact with health care professionals is recorded, and the care plans are reviewed regularly. Visitors commented, “The care seems The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 11 good”, and “The care is very good”, and a staff member also commented, “the care is very good”. A statement on a comment card received by the commission mentioned that a resident had been unable to reach the alarm bell when they had fallen. This was discussed with the deputy manager who confirmed that the manager has made appropriate arrangements to deal with this problem. Medication storage, and the recording of receipt, administration and disposal of drugs is sufficiently detailed to enable an audit trail. The home has a homely remedies policy and a policy for self-administration of medication, and risk assessments are undertaken for both of these. All staff who administer medication have received training. Staff were seen to treat residents with respect and uphold their right to privacy. A comment on one of the homes quality questionnaires completed by a visitor included, ‘the staff appear to treat the residents with courtesy, and as much as possible as individuals’. The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents would benefit from a more structured activities programme. Residents are given choices in their daily lives; their visitors are made welcome in the home; and they receive a varied diet. EVIDENCE: A variety of activities are offered to service users including the library, the use of visiting entertainers, a visiting hairdresser, and visiting religious leaders. Residents are asked during residents meetings if there are other activities that they would enjoy. However one resident commented, “We don’t have many activities”, and a staff member said, “there are not enough options of activities”. The acting manager stated that the home are to employ a dedicated activities coordinator twice a week within the next couple of months, and a recommendation has been made that this takes place and that a The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 13 structured activity programme is produced. General comments from residents included, “I played draughts the other day”, and “We are playing dominoes today”. A staff member commented, “I have done Bingo with the residents sometimes”. Visitors are welcomed to the home and there are no restrictions on visiting times other than at residents own request. A visitor confirmed that he is always made welcome, offered tea or coffee or at liberty to make some for himself; another visitor commented, “They make me welcome”. Staff confirmed that visitors are always welcome and offered tea or coffee. Staff and residents confirmed that residents have choices in all aspects of their daily lives. The home has found it difficult to employ a dedicated cook and therefore some of the carers undertake the cooking on days when they are not caring. The main meal of the day is always freshly cooked and there are always a variety of alternatives available from the freezer. Fresh vegetables are provided daily. At tea time there is also a choice and a sweet trolley. Residents cultural needs and likes and dislikes are taken into account when planning meals. There is a list in each resident’s room with the alternative lunch and tea menus that are available. Minutes of a residents meeting confirmed that they are asked for suggestions for meals. Residents commented, “I enjoy my food, I always ask for small portions, we get a choice of meals”. “Sometimes the food is good”. “The food is sometimes better than others”. Visitors commented, “I always have lunch, its absolutely fantastic, good wholesome food and they give as many choices as possible”, and “The food is excellent with lots of nourishing fresh vegetables”. One service user said, “Tea as a last meal is insufficient choice”, this was discussed with the deputy manager who has agreed to offer a sandwich with the evening drink to residents who would like this option. The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that their concerns will be taken seriously and investigated and that they will be protected from abuse EVIDENCE: The home has a clear complaints policy and procedure and a copy is kept in each bedroom and also in the statement of purpose available in the hallway. There have been 2 complaints since the last inspection and both have been satisfactorily resolved. All complaints are fully recorded, investigated, and the outcomes are also recorded. Staff confirmed they would know how to deal with a complaint. A resident commented, “Its lovely here, they are very good, If anything was wrong I would pipe up”. A visitor commented, “I did have an issue but they responded very quickly and now there is no problem, they deal with any concerns very quickly” The home has a policy for the protection of vulnerable adults. All staff are checked against the Protection of Vulnerable Adults register. Staff have been trained in adult protection issues, and those spoken with confirmed they would The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 15 know what to do if they suspected abuse were taking place, they also confirmed that they understood the whistleblowers policy The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is clean, safe attractive, and well maintained with bedrooms that meet their needs. EVIDENCE: The home is situated in a quiet cul-de-sac and has dedicated car parking at the front. It is well maintained and comfortable and the communal rooms allow residents to sit in a variety of places. There are doors between the main lounge and the lounge dining room that can be closed to allow for privacy when needed. The home has stair lift access to the first floor and the existing The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 17 2-stage stair lift is to be replaced in the coming year with one that will travel the whole distance. Radiators throughout the home are covered to protect the residents from harm. All windows on the first floor are fitted with window restrictors. The home has an ongoing maintenance programme and improvements since last inspection include, new carpets in the lounges and hallways, 2 rooms redecorated and carpeted, 3 bedrooms with new curtains, 2 new windows have been fitted, the front tarmac has been replaced, and the damp course has been replaced in some bedrooms, There are 12 bedrooms, 10 for single occupancy and 2 for shared occupancy. All bedrooms have en-suite toilet and washbasin, and all but 2 also have a shower. Residents are able to bring in pieces of their own furniture or belongings to personalise their rooms. Residents have a lockable facility in their room. Residents commented, “My room is very pretty and comfortable”, and “I have my own pictures”. The home is clean and well maintained. General infection control measures are in place and include liquid soap and paper hand towels in all communal use areas. A staff member commented, “we have gloves and aprons, special aprons for the kitchen, and colour coded cloths and mops”. Currently the home does not have a washing machine with sluice and disinfection programmes and this is recommended. A resident commented, “the home is clean and comfortable”. Staff comments varied from, “The cleanliness is pretty good”, to “We could do better with cleanliness”. Visitors commented, “Its always clean, never any odour”, and “Infection control is good”. The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are cared for by a sufficient number of staff, trained to meet their needs. Recruitment practices are sound and protect the residents but staff files need to be updated to meet the current requirements. EVIDENCE: There are sufficient numbers of staff on duty to meet the needs of the service users. 66 of the care staff are trained to NVQ level 2 and 3 others are currently undertaking this training. The senior carer commented, “I now have my NVQ 3.” Recruitment processes for the home are sound. No new member of staff starts work in the home until 2 satisfactory references have been received, a Criminal Records Bureau Enhanced Disclosure has been submitted, and a The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 19 satisfactory check of the Protection of Vulnerable Adults register has been received. Staff files need to be looked at and updated to comply with the revised Schedule 2 and a recommendation has been made regarding this. Staff training in the mandatory subjects is up to date or booked for all staff. Since the last inspection all staff have been trained in Adult Protection, and all but one have been trained in dealing with dementia. All staff who deal with administration of medication have been trained to undertake this task. Residents commented, “The Girls are always polite”, “the staff very nice and kind”, and “they are good here”. A visitor commented, “They are very polite”; and staff commented, “It’s a nice atmosphere, friendly”, “The staff get on well”, and “I love it” The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that and an open and inclusive atmosphere, and competent management of the home will support their needs. Residents are fully involved in decision making in the home. The health, safety and welfare of residents and staff is protected. The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager has the appropriate qualifications and experience to manage the home. She is supported by a deputy who is currently also working in another home owned by the company but who will be shortly be employed full at The Poplars; and a Senior Carer. The home have developed a Quality Assurance system, quality questionnaires are circulated to service users and visitors. Some very positive comments have been made on the homes questionnaires, including comments from visitors, ‘the music afternoon and garden party were much appreciated’ ‘nice home, helpful staff’, and ‘ xxx is very happy and we feel she is well looked after’. Comments on visiting professionals questionnaires included, ‘ have never had any problems’, and ‘Staff are generally helpful’. The home is currently developing questionnaires for staff. Regular audits are undertaken; the home has an annual development plan; and regular residents meetings and staff meetings are held. A staff member commented, “We have staff meetings twice a year”. Comments from visitors on the day of the inspection site visit included, “the home is run to the best of their ability”, “I have a good working relationship with the home”, and “It’s a nice home”. The staff at the home have regular supervision sessions and this was confirmed by staff. The home do not hold any residents monies, these are dealt with by the resident themselves or their families or powers of attorney. There are lockable drawers or boxes available in resident’s rooms. The home has sound policies and procedures for the protection of the health and safety of residents and staff. Safety certificates are in date; and staff are kept up to date with mandatory training. The Poplars DS0000011620.V332450.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 OP12 Good Practice Recommendations The home should continues with its plan to employ a dedicated activities person; and should develop a structured activities programme to meet the needs of all residents The home should provide a washing machine with the required sluice and disinfection programmes. Staff files need to be updated to comply with the revised Schedule 2 of the regulations 2 3 OP26 OP29 The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 The Poplars DS0000011620.V332450.R01.S.doc Version 5.2 Page 25 - 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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