Inspection on 16/11/05 for The Poplars

This inspection was carried out on 16th November 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 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 02/05/06

The Poplars 22/02/05

The Poplars 09/06/04

The Poplars 09/03/04

The Poplars 18/09/03

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

CARE HOMES FOR OLDER PEOPLE The Poplars Chapman Street Market Rasen Lincs LN8 3DS Lead Inspector Mr Doug Tunmore Unannounced Inspection 16th November 2005 09:00 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 DS0000002465.V265591.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 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 DS0000002465.V265591.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Poplars Address Chapman Street Market Rasen Lincs LN8 3DS 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) 01673 843319 The Orders Of St John Care Trust Caroline Ann Osborne Care Home 40 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (25) of places The Poplars DS0000002465.V265591.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th July 2005 Brief Description of the Service: The Poplars is a care home owned by the Order of St John Care Trust; it is a purpose built single storey building located close to the town of Market Rasen. The home has 38 single rooms and one double room. The Poplars has a large secluded landscaped garden to the front an drear of the property, a large car park is provided at the front of the home. The care home provides care for forty residents, twenty five being older people over 65 years of age and fifteen who have dementia. The home offers long term care, respite care and holiday stay. The homes service users guide states that it aims to provide a secure, relaxed and homely environment in which their care, well being and comfort are of prime importance. The Poplars DS0000002465.V265591.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. The main method of inspection used was called case tracking, which involved looking at policies and procedures relating to maintaining the safety and general welfare of residents. Residents were spoken to as well as a visitor, the manager and care staff and observations were made of care practices. A partial tour of the home took place. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure that all care workers are aware of and carry out the homes infection control policy when handling continence pads and soiled clothing. The home has not enabled 50 of their care workers to gain NVQ (National Vocational Qualifications in care level 2. The Poplars DS0000002465.V265591.R01.S.doc Version 5.0 Page 6 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 DS0000002465.V265591.R01.S.doc Version 5.0 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 DS0000002465.V265591.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The above standards were not inspected on this occasion. EVIDENCE: The Poplars DS0000002465.V265591.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 & 10 An accurate record of medication given to residents is kept. There is good care planning in this home, which helps ensure that the delivery of personal care is addressed. EVIDENCE: The pharmacist inspected the home on the 17/05/05 and recorded that storage and administration records of medication is carried out appropriately and no recommendations were made. A small number of residents look after their own medication and a lockable facility is available to them for its safekeeping. Risk assessments were seen and had been signed by the resident acknowledging that they can look after their own medication needs. One resident confirmed that she looks after her morning medication and that she remembers being assessed to do so. A carer was aware of the intimate care needs of residents and those principles regarding maintaining the privacy and dignity of all those people in the home. She also confirmed that she had undertaken induction training, which addressed the bathing and toileting of residents. She said that she is to start National Vocational Training at level 3 in the near future. Residents commented that they felt that their privacy was maintained and that staff were The Poplars DS0000002465.V265591.R01.S.doc Version 5.0 Page 10 very kind and considerate. A visitor commented that ‘her mother was very well cared for and that staff never seemed to get frustrated or cross’. The Poplars DS0000002465.V265591.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The above standards were not inspected on this occasion. EVIDENCE: The Poplars DS0000002465.V265591.R01.S.doc Version 5.0 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The above standards were not inspected on this occasion. EVIDENCE: The Poplars DS0000002465.V265591.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The above standards were not inspected on this occasion. EVIDENCE: The Poplars DS0000002465.V265591.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Residents are protected by robust recruitment practices. Residents benefit from a staff team who are well trained and work well together and compliment each others skills. Night staffing levels do not reflect the needs of residents. EVIDENCE: Two personnel file seen contained CRB checks (Criminal Record Bureau), references, application forms and interview notes. Care workers have not been given and signed for The General Social Care Council Codes of Practice, which sets out their responsibilities as care workers looking after vulnerable adults. The homes training record was seen which showed that, six care workers had NVQ (National Vocational Qualifications) level 2 and one has level 3, eight staff are undertaking NVQ 2, two workers are currently undertaking NVQ level 3 training. The home does not meet the standard for 50 of staff to be trained to NVQ level 2 by 2005. Statutory training such as fire training, moving and handling and first aid are undertaken at this home. Other training undertaken included; food hygiene, first aid, safe handling of medication and adult protection. The Poplars DS0000002465.V265591.R01.S.doc Version 5.0 Page 15 One care worker demonstrated a clear understanding of her role and responsibilities. She confirmed that she had undertaken the above mentioned training. The homes rota showed that there are adequate staffing during the day to meet residents needs. However, the homes call register was seen and showed that two night care workers attended seventy five calls after 00.30 am in one night some of which required both workers attendance for individual residents. Night staffing levels must reflect the needs of residents, the layout of the home and the risks posed to residents. Comments received from a visitor was that 99 of the time there are enough staff on duty. Residents said that there has been some illness lately but staff ‘answer buzzers (call system) very quickly’. The Poplars DS0000002465.V265591.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35, & 38 The manager is qualified, competent and of good characters to carryout her duties. Records seen show that residents’ health and general welfare and safety are promoted. The home ensures that that the residents have the opportunity to voice their views and opinions. Accurate records are kept of residents’ monies. The homes cross infection policy is not always adhered to by care workers. EVIDENCE: The registered manager has nineteen years experience at differing levels of care work before becoming the registered manager of this home four years ago. She is close to completing the Registered Managers Award and NVQ level 4 in care. A care worker stated that the manager ‘is really good easy to talk to and manages the home very well’. Residents spoken to during lunch stated that we The Poplars DS0000002465.V265591.R01.S.doc Version 5.0 Page 17 see a lot of her she comes around on most days and is very friendly and approachable. The home conducts a quality assurance report. The July 2005 report has been made available to residents and relatives in the reception area of the home. The minutes of the last residents meeting held on the 07/09/05 showed that residents are encouraged to voice their views and are actively involved in issues relating to the running of the home. Residents stated that they had attended the residents meeting and could remember completing the homes questionnaire. A visitor also confirmed that she had completed the questionnaire for the home. The home only deals with personal allowances of residents, which are kept at the home. All other monies relating to funding are paid into the companies bank account on a standing order, direct debit or by check by relatives or the County Council. Residents’ personal allowances were seen and it was found that an accurate record is kept and receipts are available for any monies spent. A visitor commented that she dealt with his mother’s monies. One resident confirmed that he buys newspapers for residents and signs the accounts book when he delivers them. Another resident confirmed that she keeps her own petty cash and that she can get money when she wants it. There are a range of policies and procedures available in the home relating to fire safety and fire risk assessments. There was also evidence that fire alarm, fire drills and emergency lighting checks have been undertaken. Care staff also receive fire training as part of the homes initial training and as a regular training event. Certificates were available showing that bath hoists and wheelchairs had been serviced/cleaned. All wheelchairs seen on the day of the inspection had footplates, which were in use. However, it was noted that staff do not always use protective clothing when tending to residents intimate needs, which could lead to cross infection within the home. This issue was raised with the registered manager who dealt with it immediately. The Poplars DS0000002465.V265591.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 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 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x X X X X x STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 x x 2 The Poplars DS0000002465.V265591.R01.S.doc Version 5.0 Page 19 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. 1 Standard OP27 Regulation 18 Requirement The registered person must have regard to the size of the care home the number and needs of residents with regard to staffing levels at night. The home must make suitable arrangement for maintaining satisfactory standards of hygiene as per the homes cross infection policy. Timescale for action 25/01/06 2 OP38 15(j) 20/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP30 OP30 Good Practice Recommendations The home should meet the ratio of 50 trained members of care staff with National Vocational training level 2 by 2005. Care workers should be given The General Social Care Council Codes of Practice, which sets out their responsibilities as care workers looking after vulnerable adults DS0000002465.V265591.R01.S.doc Version 5.0 Page 20 The Poplars The Poplars DS0000002465.V265591.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 DS0000002465.V265591.R01.S.doc Version 5.0 Page 22 - 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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