Inspection on 16/12/05 for The Poplars

This inspection was carried out on 16th 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Poplars 01/11/06

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Hillview Farm

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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 347 Salisbury Road Totton Hampshire SO40 3NF Lead Inspector Nick Morrison Unannounced Inspection 16th December 2005 11:30 The Poplars DS0000063927.V273521.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 DS0000063927.V273521.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 DS0000063927.V273521.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Poplars Address 347 Salisbury Road Totton Hampshire SO40 3NF 023 8043 4269 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) Starfish Enterprise Limited Janice Elizabeth Billson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places The Poplars DS0000063927.V273521.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: The Poplars is a large Edwardian building set off the main road. It has six bedrooms for service users, a lounge, a conservatory and a kitchen/dining room. Outside there is a large garden. The home caters for younger adults with learning difficulties and aims to support people to develop the skills they might need in order to move on to more independent living. The home is owned by Starfish Enterprises and the Registered Manager is Jan Billson. The Poplars DS0000063927.V273521.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of this home, which was registered in July 2005. The inspection concentrated on the key inspection standards. The Inspector toured the premises, spoke with the Manager, two staff and two service users and looked at relevant files and records. The inspection lasted four hours. What the service does well: What has improved since the last inspection? 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 DS0000063927.V273521.R01.S.doc Version 5.0 Page 6 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 DS0000063927.V273521.R01.S.doc Version 5.0 Page 7 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 Service users benefit from having their individual needs and aspirations assessesed prior to admission. EVIDENCE: Service users’ files showed that thorough assessments had been completed prior to admission for all service users. Care Management assessments were in place and these were supplemented by the home’s own, in-depth assessment. The assessments were being used to identify specific needs and develop care plans for service users. The Poplars DS0000063927.V273521.R01.S.doc Version 5.0 Page 8 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 and 9 Service users benefited from having appropriate care plans and risk assessments in place and were supported to make decisions about their own lives. EVIDENCE: Each service user had an individual care plan in place that reflected the needs identified through the assessment process. The plans were specific enough to describe what support each person required and the way in which they needed to be supported. The format of the plan was not rigid and could be adapted to each service user depending on their needs. The home had a person-centered approach to planning with service users and each person living in the home had been as fully involved as possible in their own plan. The service users spoken with were fully aware of their plans and confirmed that they had been involved in devising it and felt they had ownership of their plan. Service users also confirmed that the plans were reviewed on a regular basis with them. The manager and staff at the home were clear about the right of individuals to make decisions for themselves. There was clear documentary evidence in service users’ files demonstrating that service users were supported in making decisions. Service users were encouraged to make their own decisions and to learn from them if they turned out to be the wrong decision for them. The Poplars DS0000063927.V273521.R01.S.doc Version 5.0 Page 9 Where an element of risk had been identified for service users there were risk assessments in place to help minimise the likelihood and possible effects of the risk. Service users spoken with were aware of these and had been involved in devising and reviewing the risk assessments. The Poplars DS0000063927.V273521.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): 12, 13, 15, 16 and 17 Service users benefited from being involved in appropriate activities and using the local community. Their rights were respected and they were supported with their relationships. EVIDENCE: Activity plans were in place for each service user and staff supported them to be involved in activities they enjoyed. People living in the home were encouraged to continue with activities they enjoyed before moving into the home and encouraged to try new activities. There was support for service users to take up opportunities to earn money and support with benefits and financial issues. One service user was beginning to use the local college to develop educational and employment skills. The home has a positive policy regarding supporting service users with relationships. There was a clear acceptance of the service users’ needs as young adults and encouragement to develop relationships with each other and members of the wider community. The home uses the services of a specialised counsellor to support service users with personal relationships within a framework of encouraging self-development and supporting people to manage The Poplars DS0000063927.V273521.R01.S.doc Version 5.0 Page 11 risks. One service user was supported to use e-mail to maintain regular contact with her family. The rights and responsibilities of service users were acknowledged and supported through individual care plans. Service users confirmed they had keys to their rooms and opened their own mail. They also said that staff respected their privacy and would always knock on doors before entering. Service users were able to choose to spend time on their own when they wished but had ample opportunity to talk with staff when they wished. Service users did have responsibilities for household tasks and these were carried out in a straightforward way but without being the only focus of the service user’s day. Menus showed that service users received an interesting and varied diet based on their individual choices and needs. Service users confirmed that they were involved in choosing, planning and cooking meals and were able to eat out as well. The Poplars DS0000063927.V273521.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, 19 and 20 Service users benefited from receiving support in the way they preferred, having their healthcare needs met and were protected by the home’s medication policy and practices. EVIDENCE: Individual care plans were devised with the involvement of service users and contained explicit information throughout about the way in which each person preferred to be supported. Plans also described the physical nad health needs of service users and records demonstrated that these were regularly monitored and that service users were supported to access relevant healthcare services as necessary. An appropriate medication policy was in place in the home. Only one service user had medication prescribed at the time of inspection and staff administered this. Staff involved in administering medication had received training in the past and the home was in the process of planning to use the local chemist to provide medication in pre-packed doses and to provide relevant training to all staff in the home. The Poplars DS0000063927.V273521.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 and 23 Service users benefit from having their views listened to and are protected by the home’s policies and approach to dealing with abuse. They would be further protected by the implementation of staff training. EVIDENCE: Service users spoken with confirmed that staff listened and responded to their views. There was a clear complaints policy in place, which was available to each service user. Service users were encouraged to highlight any issues they were not happy with and these were recorded and responded to. Records were kept of any complaint made. The home has adequate policies in place regarding responding to issues of potential or suspected abuse. Staff at the home had had training in the past in responding to abuse but the home was planning it’s own training for all staff. A recommendation has been made that these plans are realised and that training is delivered to all staff in the home. The home also works in a preventative way with service users by using external professionals to work with service users to promote individual safety. The Poplars DS0000063927.V273521.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 and 30 Service users benefited from living in a comfortable, safe and clean environment. EVIDENCE: The home is newly refurbished to a good standard. The decoration of the home has been designed to be contemporary reflecting the fact that service users are young adults. The furnishings in the home are of good quality and contribute to a relaxed, homely feel to the house. Records showed that the home is regularly checked for safety and to ensure that it is comfortable and appropriate for service users. The home was clean throughout without being a clinical environment. Service users were supported to be involved in maintaining the cleanliness of the home and staff ensured that all areas were as clean as they needed to be. The Poplars DS0000063927.V273521.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): 32, 34 and 35 Service users benefit from being supported by competent staff and are protected by the home’s recruitment policy and practices. EVIDENCE: Staff had been recruited specifically for their experience in supporting young people with learning difficulties and this was demonstrated through their application forms and the selection interviews. Staff observed on the day of inspection were able to demonstrate an understanding of the needs of young people with learning difficulties. Staff recruitment records showed that all necessary employment checks, such as references and Criminal Records Bureau checks, were undertaken and completed prior to staff beginning work. Staff had probation periods and received copies of their terms and conditions of employment. The staff employed at the home had received relevant training through their previous employment. The home has not yet completed an analysis of the training needs of staff or produced a training plan. A recommendation has been made in respect of this. The Poplars DS0000063927.V273521.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, 39 and 42 EVIDENCE: The Registered Manager in the home is experienced in managing homes for young people with learning difficulties and is suitably qualified. She is focussed on the needs and aspirations of service users and manages the home around these. There are some quality assurance processes in place within the home, but these are limited as the home is quite new. The views of service users are regular sought and recorded. The manager is currently working on an evaluation of the home and the organisation has a stated commitment to introducing a quality assurance system. The provider undertakes regular inspections of the home and provides the Commission for Social Care Inspection with copies of these. The home needs to introduce a coordinated quality assurance system based in seeking the views of service users and other relevant people and needs to use the information gained to produce an annual development plan that can be The Poplars DS0000063927.V273521.R01.S.doc Version 5.0 Page 17 shared with interested parties. A requirement has been made in respect of this. The Poplars DS0000063927.V273521.R01.S.doc Version 5.0 Page 18 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 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 2 X CONDUCT AND MA GEMENT OF THE HOME 3 PERSO L AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Poplars Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 3 X DS0000063927.V273521.R01.S.doc Version 5.0 Page 19 na 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 YA39 Regulation 24 Requirement The provider must introduce a coordinated quality assurance system based in seeking the views of service users and other relevant people and must use the information gained to produce an annual development plan that can be shared with interested parties Timescale for action 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA23 YA35 Good Practice Recommendations The home should implement the plan to provide all staff with training in responding to suspected abuse The home should complete the analysis of staff training needs and produce a plan to meet all training needs. The Poplars DS0000063927.V273521.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 DS0000063927.V273521.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. Re-publishing this information is in breach of the terms of use of that website. 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