Inspection on 15/12/05 for The Poplars

This inspection was carried out on 15th December 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Poplars 10/09/09

The Poplars 14/08/08

The Poplars 10/03/08

The Poplars 17/09/07

The Poplars 08/09/05

The Poplars 08/02/05

The Poplars 21/10/04

The Poplars 19/02/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 The Poplars Drayton Road Abingdon Oxfordshire OX14 5HY Lead Inspector Catherine Kane Unannounced Inspection 15th December 2005 12:50 The Poplars DS0000013126.V272354.R01.S.doc Version 5.0 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 DS0000013126.V272354.R01.S.doc Version 5.0 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. The Poplars DS0000013126.V272354.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Poplars Address Drayton Road Abingdon Oxfordshire OX14 5HY 01235 523630 01235 523630 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) Caretech Community Services Limited Mr Gordon Mackay Care Home 6 Category(ies) of Learning disability (6) registration, with number of places The Poplars DS0000013126.V272354.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Admittance of one named over age service user Date of last inspection 8th September 2005 Brief Description of the Service: The Poplars is a large detached house situated within easy reach of Abingdon town centre. The home is registered for up to six people with learning disabilities. The home has a spacious lounge, kitchen and dining room and a large garden with patio area. Each resident has their own bedroom. Each resident is supported to use local health care facilities. The home is run and managed by CareTech Community Services Ltd, a national organisation with experience in providing services for people with a learning disability. The Poplars DS0000013126.V272354.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit took place during the afternoon of Thursday 15 December 2005. The manager and staff did not know the inspector was planning to visit. The purpose of the visit was to see how the home is meeting National Minimum Standards. The visit took just over two hours and the inspector spent this time with four residents who currently live at The Poplars. The inspector also spoke with the manager and met five staff who work in the home. The inspector also read notes kept in the home. The registered manager provided an Action Plan following the previous inspection stating that a requirement would be met within the timescale set. This was found not to be the case. The timescale has therefore been extended. CSCI will need to consider what enforcement action will be taken if the requirement is not met within the new timescale. The inspector would like to thank each resident for taking the time to speak with her and thank the manager and staff for their assistance during the inspection. What the service does well: What has improved since the last inspection? The home has improved how it keeps note of the activities residents take part in. The Poplars DS0000013126.V272354.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Poplars DS0000013126.V272354.R01.S.doc Version 5.0 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 The Poplars DS0000013126.V272354.R01.S.doc Version 5.0 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 the following standard(s): 2 The home has a clear admission procedure. EVIDENCE: It is important to make sure that the home is the right place, the wishes of all the people who already live in the home are carefully considered and the staff team have the right skills before offering a place to any new resident. There have been no new admissions to this home since the last inspection. The Poplars DS0000013126.V272354.R01.S.doc Version 5.0 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 the following standard(s): 6 and 9 Care plans include risk assessments and had all the essential information staff need to be able to care for residents. Residents’ care plans and other record keeping systems used in the home could be improved. EVIDENCE: The inspector viewed the care plan files for all six residents; each had the essential information that staff need to be able to care for people. The care plans are split over two files but are still large and cumbersome with a lot of information in them. Basic information, risk assessments and individual support requirements need to be quick and easy to read for new staff or agency staff so that they can provide the right care support for the people who live in this home. Care plans seen were not person centred. The inspector recommends that a person centred care planning system be introduced that includes how the home plans to take into consideration residents’ hopes and wishes for their future. The Poplars DS0000013126.V272354.R01.S.doc Version 5.0 Page 10 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): 13, 15 and 16 The home has improved how it keeps note of the activities residents take part in. Some residents’ privacy in their bedrooms and freedom to move around the home continues to be compromised by the unsuitable locks fitted on some residents’ bedroom doors. EVIDENCE: A record is now being kept that covers in detail what activities are being offered to residents. The manager showed a series of photographs of residents taking part in their favourite pastimes that could be developed into a useful communication tool for residents. Staff keep a record of how they support residents to keep in touch with their family and friends. The Poplars DS0000013126.V272354.R01.S.doc Version 5.0 Page 11 A requirement made at the previous inspection for the registered manager to do something about the unsuitable locks on residents’ bedrooms doors had not been addressed as confirmed in writing in the Action Plan provided by the registered manager following the inspection of 8 September 2005. The timescale has therefore been extended. CSCI will need to consider what enforcement action will be taken if this requirement is not met. The Poplars DS0000013126.V272354.R01.S.doc Version 5.0 Page 12 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 and 19 There was insufficient information to indicate that staff help residents to get to see their local GP, dentist and other community healthcare services when it is needed. EVIDENCE: Information needed by staff to be able to provide personal care support was included in care plans. However, the system in place to record the outcomes of residents’ visits to their GP, dentist or optician had not been fully completed for each resident. Health Action Plans had been made. The inspector recommends that the standards of recording are improved to give sufficient information to indicate that each resident is offered the opportunity to have at least an annual health check with their GP, dentist, optician or any other healthcare specialist as required. The Poplars DS0000013126.V272354.R01.S.doc Version 5.0 Page 13 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 The complaints procedure is easy to follow. EVIDENCE: The registered manager related that he has received no complaints. The Poplars DS0000013126.V272354.R01.S.doc Version 5.0 Page 14 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, 28 and 30 Hygienic conditions in the rundown kitchen have deteriorated further. EVIDENCE: The registered manager informed the inspector that the planned refit of the kitchen had been agreed with the landlord for January 2006. Since the last visit to the home the home has had to deal with an infestation of cockroaches in the kitchen. The registered manager stated that a pest control service was called to deal with this. However, one resident stated at the inspection that cockroaches were still to be found in the kitchen cupboards. The registered manager must consult without delay with the local authority responsible for environmental health for advice on good hygiene practice in the home. The Poplars DS0000013126.V272354.R01.S.doc Version 5.0 Page 15 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): Standards 32, 34 and 35 were assessed at the inspection that took place on 8 September 2005. EVIDENCE: The Poplars DS0000013126.V272354.R01.S.doc Version 5.0 Page 16 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 The management of this home is satisfactory overall but some improvements could be made to how records are kept. EVIDENCE: The manager is very popular with residents and well respected by his staff team. He has successfully managed this home for several years and has completed the Registered Managers Award. Past internal quality standards audit made available by the manager indicated the manager and his staff team run a well organised home. However, the most recent internal quality standards audit highlighted that some improvements could be made. From records kept in the home viewed during this inspection it was found that an incident that must be reported to CSCI without delay under the Care Homes Regulations 2001, Regulation 37 had not been made. The registered manager must comply with the Care Standards Act and relevant regulations. The Poplars DS0000013126.V272354.R01.S.doc Version 5.0 Page 17 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 X 3 X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X 2 X 2 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 3 16 1 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Poplars Score 3 2 X X Standard No 37 38 39 40 41 42 43 Score 3 X X X X X X DS0000013126.V272354.R01.S.doc Version 5.0 Page 18 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 YA16 Regulation 17(1)(a) Schedule 3 3(q) Requirement Timescale for action 31/01/06 2 YA30 13(3) 16(2)(j) 23(5) 3 YA37 37(1)(e) The registered manager must consult with each resident and where the resident is not able, or does not wish to use a lock on their bedroom door, this must be clearly recorded through the care planning process. Where locks are fitted these must be of a type that can be openable from outside in an emergency and cannot be locked from the outside so to prevent a resident leaving their room if they wish. (This is an outstanding requirement from the previous inspection - 08/09/05) The registered person must confirm in writing to CSCI that this has been done. The registered manager must 15/12/05 consult without delay with the local authority responsible for environmental health for advice on good hygiene practice in the home. The registered manager must 15/12/05 comply with the Care Standards Act and relevant regulations. The Poplars DS0000013126.V272354.R01.S.doc Version 5.0 Page 19 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 YA6 Good Practice Recommendations The inspector recommends that a person centred care planning system be introduced that includes how the home plans to take into consideration residents’ hopes and wishes for their future. The inspector recommends that the standards of recording should be improved to give sufficient information to indicate that each resident is offered the opportunity to have at least an annual health check with their GP, dentist, optician or any other healthcare specialist as required. 2 YA19 The Poplars DS0000013126.V272354.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 DS0000013126.V272354.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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