Inspection on 19/10/05 for The Poplars

This inspection was carried out on 19th October 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

The Poplars 13/03/07

The Poplars 01/03/06

The Poplars 01/02/05

The Poplars 15/11/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE The Poplars 4 Glen Eyre Way Bassett Southampton Hampshire SO16 3GD Lead Inspector Janet Shipman Unannounced Inspection 19th October 2005 10:00a X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Poplars DS0000011620.V259711.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 DS0000011620.V259711.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Poplars Address 4 Glen Eyre Way Bassett Southampton Hampshire SO16 3GD 023 8067 7831 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs K Cox Miss J Cox Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15), Physical disability over 65 years of age (4) of places The Poplars DS0000011620.V259711.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Not more than 4 service users in the category PD(E) are to be accommodated at any one time 1st February 2005 Date of last inspection Brief Description of the Service: The Poplars is registered under Penhaligon Limited and is located in Bassett, a residential district of Southampton close to local amenities. The Poplars provides accommodation for 15 older persons in 9 single rooms and 3 double bedrooms, all of which have en-suite toilet and bath/shower facilities. The home has a stair lift to access the upstairs level. There is a parking area at the front of the house and a garden at the rear. The registered manager is Miss Jodie Cox who is also one of the Registered Persons in Control. The Poplars DS0000011620.V259711.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 unannounced visit to the home this year. The Inspector was assisted throughout the inspection by the manager of the Poplars and the manager from its sister home Penhaligon. The inspector spoke with three members of staff and observed the interactions between staff and service users. The inspector spoke with four service users and two relatives. What the service does well: What has improved since the last inspection? What they could do better: The Poplars DS0000011620.V259711.R01.S.doc Version 5.0 Page 6 Develop a robust quality monitoring system, which is based on a systematic cycle of planning, action, review and reflecting aims and outcomes for service users. Implement a regular formal supervision process for all staff. 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 DS0000011620.V259711.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 DS0000011620.V259711.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): 1&2 Prospective service users are provided with the information they need to make an informed choice about whether they want to live in the home. EVIDENCE: The homes current statement of purpose and service user guide has been reviewed and updated. The service user guide has been simplified with the aid of photographs, which are in the process of being added to the document. The home has produced an information pack for prospective users, which includes the statement of purpose, service user guide, contract/terms and conditions of stay and a leaflet about the home. This information is presented in a glossy folder with has a picture of the home on the front. The manager agreed to send an information pack to the CSCI when the service user guide is completed. The home has addressed the issues raised at the last inspection regarding the contract/terms of conditions, which are now given, on admission rather than at the end of the trial period. The contract also now states the room to be occupied and the fees to be paid. Standard 6 was not assessed, as home does not provide intermediate care. The Poplars DS0000011620.V259711.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): 7, 8, 9 & 10 Care plans are detailed, outline how the care should be delivered and agreed by the service user. Health care needs are met by the home in conjunction with specialist services. The home’s medication procedures are robust. Service users say they are treated with respect and have their privacy protected. EVIDENCE: The care plans seen are generated from a detailed assessment. Service users have signed a copy of the care plan. The care plans give clear guidance to staff on how to meet individual service user’s needs. Records indicated that care plans are reviewed once a month and updated to reflect changing needs. Individual risk assessments are carried out and now include risk assessments for service users who have been assessed as having a risk of falls. Guidelines still need to be produced for anyone who uses a bed rail whether it has been purchased by the individual or by the home. The health care needs are met in conjunction with medical specialists. District nurses, G.Ps etc. Service users are able to have a choice of their own GP or a GP from the surgery used by the home. Dentists, opticians, chiropodists and The Poplars DS0000011620.V259711.R01.S.doc Version 5.0 Page 10 hairdressers visit the home, but service users can also access their own choice of provider. Service users weight is monitored and records kept. The home is in the process of introducing nutritional assessments, which will be viewed at the next inspection. Recently the home has changed to Lloyd’s medication system which the manager and staff spoken to by the inspector said they were finding it much more easier to use. The medication records were checked and found to reflect the current medication stored. A number of service users self medicate and special green boxes have been supplied by Lloyd’s pharmacy for this purpose. Risk assessments are also in place for service users who self medicate. One service user has controlled medication and this was appropriately stored and medication records matched the stock held. Policies and procedures have been developed by Lloyd’s pharmacy who also provides the staff training. Throughout the inspection the care staff were observed interacting with service users in a respectful and dignified manner. Service users spoken to felt that staff were “friendly and caring” that staff listened and “sorted things out”. Locks are fitted to all doors and appropriate screens are provided in double rooms. The home is currently replacing the lockable tins in service users bedrooms with new bedside cabinets with a lockable top draw. Six bedside cabinets have already been purchased. A number of service users have their own private telephone in their room. The home has a cordless telephone, which can be taken to service user’s bedroom if required. The Poplars DS0000011620.V259711.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): 12, 13, 14 & 15 Service users enjoy a variety of activities and are encouraged to pursue their own interests. Visitors are encouraged and are able to spend time with the service users in private. Autonomy and choice is promoted in the home. A full and varied menu was on offer to service users. EVIDENCE: A requirement from the previous inspection been met in respect of ensuring that routines of daily living and activities are made available to suit the needs of service users and that these are recorded. An activities coordinator had been employed by the home but the feedback from service users was that they did not like the way the activities were run and did not like the group type activities. The home has now set up an activities book, and staff record the activities that they have undertaken with an individual service user the date and duration of the activities. Activities range from manicures, craft activities, playing cards, chatting facials, and walks. The mobile library visits on a regular basis and a number of service users spoken to described themselves as keen readers. All service users have a ‘preferred daily schedule’ kept on their care planning file which set out clear guidelines on how to meet a service user’s needs from time they would like to get up, when to have their breakfast - up to the time they go to bed. The Poplars DS0000011620.V259711.R01.S.doc Version 5.0 Page 12 The inspector discussed the need to expand the care-planning format to enable a more detailed section on leisure, social and recreational interests both within and outside the home. This was agreed by the manager and will be implemented as soon as possible and will be subject to review at the next inspection. Visitors of service users and friends are encouraged, with the permission of the service user. Service users spoken to say that their visitors can come and ‘stay as long as they wished’. Some service users go out with their friends or relatives. One service user told the inspector that she has some friends who come to visit her to play cards or bridge and showed the inspector her card table in her bedroom. Different religious interests are catered by visits from local ministers. The manager confirmed that all service users, or family/advocates handle personal financial affairs. Service users rooms, possessions inventories and admission records indicated service users are encouraged to bring personal possessions into the home. The menus indicated a varied and well balanced diet. Alternative meals are available. The food is purchased from the local supermarket. The inspector was able to see the meals prepared by care staff, which looked wholesome and nicely presented. Most service users spoken to said that they liked the meals, however, some dissatisfaction was expressed that the menu can be bland and very similar. The manager has agreed to speak to individual service users with regard to their preferences for meals for the new winter menu. Drinks are available throughout the day and service users can have a snack at anytime. Service users are also asked if they want to have their meals and drinks in their room or in the main dining room. The Poplars DS0000011620.V259711.R01.S.doc Version 5.0 Page 13 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): 16 The home has a complaints policy and procedure, which, is clear and accessible. EVIDENCE: The complaints log has been changed to comply with data protection. There have been four complaints since the last inspection these have been addressed appropriately and recorded fully in the service user’s file. Service users and relatives spoken with during the inspection confirmed that they knew how to make a complaint if they were unhappy with the service. The Poplars DS0000011620.V259711.R01.S.doc Version 5.0 Page 14 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): 24 & 26 Service users bedrooms are adequately furnished and personalised with service users own personal items and furniture. The home was clean, hygienic and free from adverse odours. EVIDENCE: The home is well furnished and equipped. From observations of bedrooms and discussion with service users and their relatives, service users are able to bring in their own personal furniture and possessions. Screens are provided in double rooms. All bedrooms have en-suite toilet and wash hand basin. One service user’s bedroom has a fire exit door, the manager reported that this was not used. The manager must contact the Fire Officer for advice on whether the door is still required as a fire exit. If it is not required as a fire exit then more room could be made available to store the service user’s wheelchair. A couple of service users told the inspector the difficulty in using a wheelchair on the gravel driveway at the front of the house. This matter was discussed with the manager, who had the gravel laid because of potholes in the existing The Poplars DS0000011620.V259711.R01.S.doc Version 5.0 Page 15 drive. The manager agreed to look at ways in which the driveway could be made more accessible for service users who use wheelchairs. It was apparent during the tour of the home and talking to service users and staff that the cleanliness of the home was well managed. The Poplars DS0000011620.V259711.R01.S.doc Version 5.0 Page 16 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): 29 & 30 The home has an up-to date recruitment procedure and recruitment records were complete. Staff are now undertaking the TOPSS induction-training programme to meet the National Training Organisation targets. EVIDENCE: The manager has updated the home’s recruitment procedure, which now includes the POVA and CRB guidelines. All staff employment records were looked at and were found to contain enhanced criminal record certificates and the necessary employment records, as well as copies of birth certificates and driving licence. The home now accesses TOPSS induction training through Fareham College. The course in run locally in Southampton. Each member of staff has an induction checklist in their file and a training record. The manager has also produced a training matrix identifying the mandatory training undertaken by staff for the current year. The Poplars DS0000011620.V259711.R01.S.doc Version 5.0 Page 17 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): 33 & 36 There is a quality assurance system in place, which seeks the views of relatives and professionals. However more work needs to be done to include service users views and ensure that the quality assurance system is systematic and reflects the aims and outcomes for service users. Staff supervision has been carried out on an informal basis but not recorded. The requirement to carry out formal recorded supervision sessions at least six times a year and an annual appraisal has not been met. EVIDENCE: The home has introduced a quality assurance system through quality questionnaires being completed by relatives and visiting professionals and these were viewed by the inspector. The manager also plans to seek the views of service users by using a questionnaire, although this has not been successful in the past. The manager must ensure that the quality assurance system is based on a systematic cycle of planning, action, review, reflecting the aims and outcomes for service users. The results of surveys and the action The Poplars DS0000011620.V259711.R01.S.doc Version 5.0 Page 18 plan must be published and made available to current and prospective users, their representative and other interested parties, including the CSCI. The manager reported that staff supervision is mainly carried out on an informal basis by observing staff practice, however, this has not been recorded. Only one formal staff supervision has taken place in October 2005. Therefore the previous requirement to ensure that all staff have regular recorded supervision sessions at least six times a year and an annual appraisal has not been met and the requirement will be repeated for the second time. The Poplars DS0000011620.V259711.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X 3 X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X 2 X X The Poplars DS0000011620.V259711.R01.S.doc Version 5.0 Page 20 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 OP36 Regulation 18(1) Requirement Timescale for action 31/01/06 2 OP33 24(1) The registered manager must ensure that all staff have regular recorded supervision sessions at least six times a year and appraisal, which also identifies training and development requirements. This requirement has been repeated for the second time. A further failure to comply will result in further action being taken. The registered manager must 31/01/06 ensure the home has an effective quality assurance system, which includes feedback from service users. Results from surveys are published and an action plan developed which is then made available to current and prospective users, their representatives and other interested parties, including the CSCI. This requirement has been repeated for the second time. A further failure to comply will result in further action being taken. DS0000011620.V259711.R01.S.doc Version 5.0 The Poplars Page 21 3 OP38 23(4 a,b) The registered manager must 31/01/06 seek advice on whether Bedroom 3 Fire Exit is still required. 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 DS0000011620.V259711.R01.S.doc Version 5.0 Page 22 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 DS0000011620.V259711.R01.S.doc Version 5.0 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!