Inspection on 17/09/07 for The Poplars

This inspection was carried out on 17th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 9 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 15/12/05

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 Nancy Gates Unannounced Inspection 17th September 10:00 The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 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.V348403.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 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.V348403.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Poplars Address Drayton Road Abingdon Oxfordshire OX14 5HY 01235 523630 01235 523630 haroon@caretech-uk.com 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 Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Admittance of one named over age service user Date of last inspection 7th September 2006 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 who have a learning disability. The home has a spacious lounge, kitchen and dining room and a large garden with patio area. Each resident has his or her 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 fees for this home range from £997.72 to £1,015.19. The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of the service was a surprise visit and was a ‘key inspection’. The inspector arrived at the service at 10.00 a.m. on a weekday. The total number of hours spent at the home was 8 hours. The time spent at the home allowed for a thorough look at how well the service is doing. The inspection took into account detailed information provided by the service manager inclusive of information that CSCI has received about the service since the last inspection. The inspector asked for the views of the people who use the service. The inspector also asked the views of others who support the needs of the people who use the service via a questionnaire that the CSCI sent out. All information received by the Commission for Social Care Inspection since the last inspection, about this service was also taken into account when producing the key inspection report. Staff and the people who live at The Poplars were very welcoming. The inspector looked around the home including the bedrooms of individuals at their invitation. A number of records were viewed including resident’s care plans, staff recruitment records, staffing rotas and maintenance/health and safety records. The inspector looked at how well the service was meeting the standards set by the government. The report includes judgements about the standard of the service. The inspector would like to thank the manager and his staff team for their assistance with the inspection. Thanks also to the people who use the service, visitors and all others who shared their experience of this home. What the service does well: Prospective residents are given information that will help them make an informed choice about where to live. The needs of prospective residents are thoroughly assessed prior to moving to The Poplars and people are given opportunity to visit the home to ensure the service can meet their needs. The health and personal care needs of people living at the home are met, promoting health and well-being. The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 6 Needs arising from equality and diversity are met, ensuring that each persons individual circumstances are taken into account. Activities are available, individual interests and choices are taken into consideration and made available. People are encouraged to be as independent as possible. Contact with family, friends and the community is supported to maintain social links. Complaints and adult protection are effectively managed to listen to views of people who live at the home and reducing the risk of harm to them. The home is generally clean and welcoming. What has improved since the last inspection? What they could do better: At the previous inspection visit, it was recommended that care plans could be improved to make them more person centred and easier to read. The support/care planning system remains outdated and needs to be changed to make sure they are person centred and easy to read. Information about the people who live at The Poplars is not held in a safe place. Information must be stored safely to ensure the protection of the people who use the service. At times agency staff were observed to have little or no interaction with individuals. Staff sat or stood away from people; staff were also seen sitting chatting to each other in the lounge and did not engage people in conversation or activities. Sometimes the privacy and dignity of people was not upheld. The staff team including staff provided by agencies must have the training and qualifications to ensure they can support people appropriately. Well-motivated and skilled staff must be recruited to reduce the use of agency staff to provide people with stability and continuity of care. Food options must be reviewed to make sure that the people who use the service are provided with a balanced diet. The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 7 The home is generally clean and comfortable, however there must be improvements made to some of the communal areas to ensure the safety and comfort of all household members. A better programme of repair and maintenance of the home to make sure people live in a well looked after home. A lack of clear management has compromised the health, safety and welfare of the people who use the service. A manager has been appointed at the home to provide leadership, guidance and direction to staff to ensure the people who use the service receive consistent good quality care. An application for registration must be submitted. 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 DS0000013126.V348403.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are given information that will help them make an informed choice about where to live. The organisation has an appropriate assessment procedure to ensure that all prospective residents support/care needs are assessed. EVIDENCE: A Statement of Purpose and Service Users Guide are available for prospective residents and provide sufficient detail of the services that can be offered at the home. The pre-admission assessment records were seen for the most recent person admitted to the home and included a care needs assessment. Admissions are not made to the home until a full needs assessment has been undertaken. The home are then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the Statement of Purpose. The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 10 A family member of the most recent person to move to The Poplars confirmed that information provided gives a clear account of what support is offered. The family member also confirmed that the assessment process was clear and involved the individual and their representatives. Prospective new residents are given the opportunity to spend time in the home. The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The overall standard of support/care planning is variable. The structure of the plans remains complex and may not be readily understood by many of the people who live at The Poplars. This does not ensure that individuals assessed needs are being fully met. The home continues to have a system for identifying and assessing risk for individuals in relation to everyday activities. The storage of support/care plans in the dining room compromises the safety and confidentiality of information. EVIDENCE: Four support plans/records were viewed during the inspection. The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 12 The plans provide adequate information as to how each person likes to be supported. The plans also relate to a person’s communication support needs. The plans give opportunity for personal likes and wishes to be prioritised, for routines to be established when people require them and for personal preferences to be acknowledged. It was highlighted at the previous inspection that, “…the files were not person centred or easy to read. The home uses a care planning system that promotes the use of charts and task checklists for staff. No improvements have been made since the last inspection.” A recommendation was made to improve the quality of the care planning system to ensure the information not only provides relevant day-to-day information but also “takes into consideration residents’ hopes and wishes for the future.” There was no evidence that significant improvement has been made to the support plans. The use of charts and task checklists remain, presenting an institutionalised/custom and practice approach demonstrating that the people who use the service are not necessarily regarded as individuals with differing needs. The plans are bulky and information about how to support individuals is difficult to find. At the time of inspection an issue relating to an individual’s support needs raised concern; the guidelines to support the person could not be easily found and left staff at a loss as to how to respond appropriately. The support/care planning system is outdated and does not provide evidence that the service provider is recognising the importance of using support/care plans which follow current, nationally recognised person centred planning principles. The two previous inspections in December 2005 and September 2006 made clear recommendations that improvement should be made. The provider must introduce a support/care planning system that provides appropriate information that ensures the participation and engagement of individuals in the process. The home continues to have a system for identifying and assessing risk for individuals in relation to everyday activities. From the evidence seen and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. The previous inspection highlighted that records and tick charts are held in the dining room compromising the safety and confidentiality of information. This remains an issue, the records are clearly held in the dining room for the The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 13 convenience of staff rather than for the protection of the people who live at The Poplars. This must be addressed. The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supported to make lifestyle choices, which generally recognise individuality. Contact with family members is supported. Food options do not offer a nutritionally balanced diet and must be reviewed to ensure the health and well being of the people who use the service. EVIDENCE: The inspector met and spoke with three people who use the service during the inspection. Two people were able to communicate with the inspector and said they were happy at The Poplars and could do things that they want to do. The other person was unable to communicate clearly but with the help of staff and notes seen during the inspection it was clear that the person was able to do The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 15 what they wanted during the day. However, there were occasions within the inspection where people were not engaged in any activity with staff. At times staff were observed to have little or no interaction with individuals. Staff were observed sitting or standing away from people; staff were also seen sitting chatting in the lounge for a period of time showing little initiative and reluctance to interact with people. This must be addressed. External Activity Support Workers (ASW) offer individuals the opportunity to go out, to go shopping, to go out for lunch or to go to an activity. People are clearly supported to decide what they want to do during the sessions with the ASW. A number of people attend college courses and a local day centre. People continue to be encouraged and supported to maintain appropriate personal and family contact. Visitors are welcomed into the home, an individual told the inspector that, “My mum visits me when I want”. The individual’s mum confirmed that contact is encouraged and welcomed. The people who use the service are asked to attend house meetings and are given opportunities to share their views on issues that are important to them. The inspector was in the home at the time lunch and the evening meal was being served. The meals were plated for all household members and if not eaten at the time of serving were stored in the oven to be re-heated when the individual decided to eat. This should be reviewed to ensure that this is in line with guidance regarding food handling/hygiene. People confirmed that they help with the menu planning and that some people help with the preparation of meals, however no individuals were engaged in the preparation of either meal during the inspection. Regular drinks and snacks are available. Menus detail that people choose what they want for breakfast, usually cereal and/or toast. The options for lunch and dinner between the 03/09/07 up to and including 30/09/07 highlight a number of convenience foods (Fish fingers and chips, burger and chips, chicken chow mien, pork pies, chicken curry and rice) with limited fresh vegetables on offer. Of the 56 lunch and dinner options recorded only 11 included vegetables, often potatoes and peas. The provider must ensure that nutritionally balanced food options are provided that meet individual need. The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who live at The Poplars are supported to meet their personal care needs, however privacy and dignity are not always upheld. Access to additional support from health care professionals is consistent and meets individuals’ health needs. Medication is stored securely and administration is accurate, ensuring the safety of the people who use the service. EVIDENCE: Support/care plans include guidance of how people wish their personal and healthcare needs to be supported. Personal care is provided in private in either people’s bedrooms or the bathrooms. People are prompted with their personal care as required and they choose their own clothes and hairstyle. Times for getting up, going to bed, The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 17 baths and mealtimes remain flexible. Support plans refer to preferred routines, likes and dislikes. An issue for concern was raised with the manager following the observation of the actions of an agency member of staff. The actions of the staff member did not uphold the dignity of and privacy for the person. Communication/ interaction with the individual was limited and at times the staff member did not speak to the person. The manager stated that the actions of the agency staff member were unacceptable and would be addressed. The registered provider must ensure that staff have the appropriate skills and competencies to support people at all times. Staff continue to help individuals to look after their own medication. People are enabled to see their local GP and other community healthcare services when needed. Staff also support people to access specialist healthcare support. Medication storage and administration records (MARs) were viewed. Two lockable cabinets, which are securely attached to the wall, ensuring the safe storage of medication. Medicines were found to be in date and stored appropriately. There were no inappropriate items stored in either cabinet. Medication administration records were well maintained with signatures alongside prescribed dose times. No omissions were noted; records were accurate and up to date. Staff administering medication had been trained and completed a period of observation before being signed off as competent. The staffing issues presented on the day of inspection (3 agency staff and a manager who had not been assessed as competent to administer medication in the home) meant that a staff member had to be called into the home to administer medication at 6 p.m. The administration of medication at 8 p.m was compromised due to no staff member being available to administer medication. The manager used the on-call facility to find a competent person to administer medication. The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an effective system in place for responding to, investigating and recording complaints. Systems and procedures are in place to ensure the protection of the people who use the service. EVIDENCE: No formal complaints have been received at the home or at the CSCI since the last inspection. A complaints procedure is available for the people who live at The Poplars. Individuals confirmed that they know who to talk to if they’re not happy with something. Adult protection/Safeguarding adults procedures are available at The Poplars. A permanent staff member confirmed attendance at training regarding the protection of vulnerable adults and was able to provide a good account of how to respond to allegations. The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally clean and comfortable, however there must be improvements made to some of the communal areas to ensure the safety and comfort of all household members. EVIDENCE: The home is a detached property, close to local facilities and shops. Most areas within the home other than some people’s bedrooms were seen with the permission and assistance of individuals. All of the shared spaces within the home are accessible for shared and private use. Communal areas were warm and decorated to a reasonable standard. The dining room contained a large table and numerous chairs. A large kitchen allows for people to make drinks and snacks whenever they wish. The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 20 A lounge area is next to the dining room, which contains comfortable sofas, a TV and DVD. Individuals’ bedrooms reflect individual tastes, containing personal effects that ensure that individuality is recognised. Individuals commented that they think the house “is a nice place…I like my room, these are all my things…I help to clean my room and sometimes have to ask the staff for a bit of help.” A tour of the building raised the following issues: Ground floor • • • Internal front door – large panel of glass cracked. Hallway – only two light fittings had working light bulbs. Kitchen – Door of one kitchen cupboard missing. Worktop surfaces grubby, skirting boards and corners of the room were dirty and stained, oven door doesn’t close properly, no blind at the kitchen window. The kitchen is functional but not homely. Kitchen/laundry room door – the previous inspection highlighted that a pane of glass in the door was broken and must be replaced. This has not been completed. This demonstrates a blatant disregard for the health and safety of the people who use the service and non-compliance with a requirement made following the last inspection in September 2006. Laundry room – very dirty windows, fire door does not fully close, frayed and unsightly net curtains hung at the windows. Garden - the garden is overgrown in areas and unkempt. An unsightly mattress was propped against the laundry wall, a bucket, bits of wood and plastic had been thrown into one of the flowerbeds. The garden does contain furniture and a BBQ for people to use in the summer. Gas Boiler – a gas boiler is situated next to a fire exit and adjacent to an individual’s bedroom, although a fire door provides protection. A part of the front cover of the boiler was missing, the large front cover was loose and provided easy access to the boiler, this does not ensure the health and safety of household members. Staff sleep in room – the room was untidy. There were numerous boxes that contained archived files; this compromises the safety and confidentiality of information. • • • • • First floor • Bathroom – flooring stained and in need of replacement. A number of carpets throughout the home have been identified as needing replacement. A quote for replacement was being obtained at the time of the inspection. The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 21 The cracked and broken pains of glass in both front and back doors compromised safety. During the inspection two maintenance people arrived to “measure up”. One person stated “I was phoned by the office about an hour ago to come and measure up…they will be replaced tomorrow.” Following the inspection the manager confirmed that the repairs/replacements were made. Failure to ensure that repairs are made to the identified areas may result in enforcement action being taken by the CSCI. The home was clean in most areas and free from odour. The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. High use of agency staff compromises the quality of service offered to the people who use the service. The home does not have sufficient permanent staff to meet identified needs. The home has safe recruitment practices in place, which safeguard the people who live at the home. Staff are offered mandatory training, which ensures that the needs of people who live at The Poplars can be met by appropriately trained staff. EVIDENCE: Upon arrival at the home, there were three agency staff on duty, no permanent staff were present. Four of the five permanent members of staff were at a training day; the other permanent staff member off sick. The manager who had been recently employed was accompanying a person to a hospital appointment. The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 23 None of the agency staff were able to produce valid identification. The manager was unable to locate details to confirm that agency staff had completed essential training, for example, first aid and basic food hygiene. While an agency staff member was able to confirm to the inspector the detail of induction they had completed when they first worked in the home there was no record available. It has been highlighted within a previous section of the report that there were occasions within the inspection where people were not engaged in any activity with staff. At times staff were observed to have little or no interaction with individuals. Staff were observed sitting or standing away from people; staff were also seen sitting chatting in the lounge for a period of time showing little initiative and a reluctance to interact with people. Upon a tour of the building staff belongings (handbags, magazines, catalogues and mobile phones) were placed on a windowsill in the dining room highlighting a lack of respect for The Poplars being individuals home. The quality of service offered to the people who live at The Poplars was clearly compromised. Leaving three members of agency staff on duty who did not support people appropriately at all times and leaving the management of the service to someone who had only been recently employed compromised the welfare of the people who use the service. The registered provider must ensure that a skilled and experienced staff team is on duty at all times. Failure to ensure that a skilled and experienced staff team is on duty at all times may result in enforcement action being taken by the CSCI. There continues to be high use of agency staff as there are numerous vacancies. The manager stated that the home used preferred staff from one agency to ensure consistency, however the skills and abilities of those staff are questioned due to the observations made during the inspection. The inspector was able to speak with one permanent member of staff who had returned from the training day to complete medication administration at 6 p.m. as there was no one available to do so (See Personal and Healthcare Support section). Staff morale remains low, as the home has been without a manager for three and a half months. Requests made by staff for maintenance issues to be addressed have been ignored; additional responsibilities have been placed with staff members with little support from senior management within the organisation. The staff member stated that the appointment of the manager would hopefully bring some stability to the home and that this should support the welfare of the people who use the service. Only one staff member has completed a relevant National Vocational Qualification (NVQ). The home continues to not meet national targets to have 50 of staff NVQ qualified. The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 24 Staff recruitment files are held at the home. The manager confirmed that appropriate recruitment checks are made by the organisation before employment. A staff member was able to confirm that appropriate training opportunities are made available. The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A manager has been appointed at the home to provide leadership, guidance and direction to staff to ensure people receive consistent quality care. An application for registration must be submitted. A lack of clear management has compromised the health, safety and welfare of the people who use the service. EVIDENCE: The manager has recently been recruited to the home, commencing employment in September 2007. The manager described a range of skills and experience for the support of the people who live at The Poplars and is aiming to achieve the Registered Manager’s Award in the future. The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 26 The manager stated that an application for registration would be submitted to the CSCI. The provider must ensure that the manager of the home submits an application for registration to the CSCI to ensure that the day-to-day and ongoing development of the service are managed effectively and the service remains in line with legislation. Staff and the people who use the service described the newly appointed manager as being supportive and knowledgeable. Action taken to respond satisfactorily to requirements from the previous inspections remains poor. Observations made during the inspection demonstrate that elements of the support provided are done so for the convenience of staff rather than for the health, safety and welfare of the people who use the service. This demonstrates a blatant disregard for the health and safety of the people who use the service and non-compliance with requirements made following the previous inspections in December 2005 and September 2006. A number of maintenance issues were highlighted by a staff member but have been ignored. For example, a request to change the water temperature, which compromised the health and safety of individuals was ignored on two occasions. A request was made on the 11.09.07 with a maintenance person due to attend on the 17.09.07. “They just didn’t bother turning up”. The manager contacted the housing provider on the day of inspection and was assured that the issues would be solved as soon as possible. The manager stated that regular visits have been undertaken by the provider to evaluate quality of care but the reports were not available. The registered provider must ensure that copies of the reports are held at the home and available for inspection. The home has appropriate policies and procedures available to protect household member and staff. A range of health and safety checks continues to be carried out at the home. Permanent staff undertake training in control of substances hazardous to health and health and safety, as well as manual handling, food handling and first aid. Data sheets were in place for cleaning products used at the home, in case of accidental spillage or ingestion. CareTech (the registered provider) has financial and accounting systems subject to internal and external audits. The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 1 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 X 2 X X 2 X The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement The registered person must introduce a support/care planning system that provides appropriate information that ensures the participation and engagement of individuals in the process. The registered person must ensure that information relating to the support needs of the people who use the service and for the conduct of the home are held securely and confidentially and in accordance with the legislation relating to Data Protection.. The registered person must ensure that all staff including staff provided by agencies are able to provide continuity of care that meets the needs of the people who use the service. The registered person must ensure that nutritionally balanced food options are provided that meet individual need. The registered person must ensure that the staff team including staff provided by DS0000013126.V348403.R01.S.doc Timescale for action 31/01/08 2. YA10 17:1 (b) 09/11/07 3. YA16 18 (b) 09/11/07 4. YA17 16:2 (i) 09/11/07 5. YA18 YA35 18(1) 09/11/07 The Poplars Version 5.2 Page 29 6. YA24 YA42 23:2 (b) 7. YA37 8&9 agencies have the training and qualifications appropriate to the work they are to perform and that accurate records of this are available for inspection. (Made at previous inspection of the 07/09/06) The registered person must ensure that repairs are made to the areas of the home identified at the time of inspection to provide a comfortable and safe home to people who use the service. The provider must ensure that the manager of the home submits an application for registration to the CSCI to ensure that the day-to-day and ongoing development of the service are managed effectively and the service remains in line with legislation. 18/11/07 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Poplars DS0000013126.V348403.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Oxford Office Burgner House, 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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. 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