Inspection on 02/05/06 for The Poplars

This inspection was carried out on 2nd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 16/11/05

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 Key Unannounced Inspection 2nd May 2006 09:30 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.V292336.R01.S.doc Version 5.1 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.V292336.R01.S.doc Version 5.1 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.V292336.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16 November 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.V292336.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took any previous information held by CSC including questionnaires sent to the home by the Commission prior to this inspection into account. The site inspection consisted of case tracking a sample of the resident’s records and assessing their care. The inspector spoke with two residents who were being case tracked two who the inspector joined for lunch, four visitors two of which were visiting community nurses and two member of staff as well as the activities organiser. The inspector also spent time with the registered manager. A partial tour of the home and a review of a sample of the records was also included. What the service does well: What has improved since the last inspection? The home has taken action to address those requirements and recommendations raised at the last inspection. Those files seen recorded how carers are to maintain the privacy and dignity of residents when undertaking their intimate care needs. The homes complaints form now has a space for complainants to sign to indicate whether they agree with the outcome of their complaint or not. The homes medication sheets were examined and it was seen that an accurate record of medication given was kept. The homes training file showed that the home has enabled 50 of their care workers to gain NVQ (National Vocational Qualifications in care level 2. All carers are aware of and carry out the homes infection control policy when handling continence pads and soiled clothing. The Poplars DS0000002465.V292336.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Poplars DS0000002465.V292336.R01.S.doc Version 5.1 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.V292336.R01.S.doc Version 5.1 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): 2&3 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Residents are admitted into the home only after a full needs assessment has been carried out either by the home and or health care or social care agencies. Written confirmation that the home can meet a prospective residents needs is also undertaken prior to admission. EVIDENCE: A review of all information available prior to this inspection and evidence seen at this inspection in residents files and care plans showed that the home does not admit residents without a care assessment being undertaken. Prospective residents are also written to by the home confirming that they can meet the residents care needs or not. Residents being case tracked were not always able to give a considered view of the care they receive due to their age and those infirmities that come with old age. The Poplars DS0000002465.V292336.R01.S.doc Version 5.1 Page 9 Questionnaires returned to The Commission show that twenty-two residents/relatives confirmed that they had information about the home prior to admission. However, eleven residents commented that they had not received a contract. The manager commented that she would check all files to ensure that contracts are available and if not issue new contracts to those residents without them. The Poplars DS0000002465.V292336.R01.S.doc Version 5.1 Page 10 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 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Residents or their representatives are involved in the care plans. The home administers medication appropriately to all residents. There is good care planning in this home, which helps ensure that the general health and welfare of residents is addressed. EVIDENCE: A review of all information available prior to this inspection and previous key inspections carried out at this home has evidenced that either residents or their relatives are involved in the care plans. Those care plans seen had been signed to confirm that residents agree with the care being provided. Two relatives seen confirmed that they have been actively involved in their relatives care plans, which have been signed by themselves. They also stated that their relative is always well dressed clean and treated with dignity and respect. The Poplars DS0000002465.V292336.R01.S.doc Version 5.1 Page 11 Care plans evidenced that health care professionals visit the home and that residents when required visit the hospital. ’Questionnaires received back from the home showed overwhelmingly that residents felt that they receive the medical support that they need. Two visiting community nurses confirmed that they visit the home weekly and have good communication with this establishment. Residents they felt were well looked after and the GP visits on a Tuesday. Residents files also showed that personal care required is documented and mention is made of maintaining the residents dignity and privacy at all times. Daily entries had been made in care plans by care staff, which identified the care given. Care staff were seen to treat residents with respect and dignity during this inspection. The homes accident book was seen and it was found that accidents occurring to residents have been recorded appropriately. This information is also made available to the Commission by the home. Two carers demonstrated that they had knowledge of giving personal care and confirmed this is addressed in the homes induction training. Medication given to residents at lunchtime by a senior carer was seen to be delivered to residents in the appropriate container in line with the homes medication policy. Medication sheets seen were found to be correctly completed by the senior on duty. The pharmacist inspected the home on the 22/03/06 and recorded that storage and administration records of medication is carried out appropriately and no recommendations were made. The Poplars DS0000002465.V292336.R01.S.doc Version 5.1 Page 12 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 The quality outcome in this area is excellent. This judgement has been made using available evidence including a visit to this service. Meals are well managed and reflect resident’s likes and dislikes. Relatives and friends of residents are made welcome in this home. A range of stimulating activities are made available to residents. EVIDENCE: The home undertakes a variety of activities for the stimulation of residents. The homes activities diary showed that on five days of the week activities are made available both by the activities organiser and care staff. The notice board also listed a weekly event within the home for the information of residents. Two visitors said that their relative is gently and quietly motivated by carers and take notice in the changes of his needs. They confirmed that they had seen activities taking place in the home, including card making, painting and aerobics to music. They also said in the summer there is a barbeque and all relatives are invited with residents, carers and their families also attend. They stated that outings take place with visits to Rothwell to see the daffodils and the local theatre. As well as local schools coming into the home they commented that their relative has his Salvation Army music played by the staff The Poplars DS0000002465.V292336.R01.S.doc Version 5.1 Page 13 at his request. The activities organiser evidenced that outside entertainers visit the home as well as coffee mornings being arranged. Questionnaires from residents/visitors demonstrated that twelve residents felt that activities were always available and ten felt that activities were usually available. All visitors confirmed that they are made welcome at the home. Two residents being case tracked confirmed that they can take visitors to their bedroom. The inspector joined two residents for lunch and found that the meal was hot and very tasty and that choices were available. Questionnaires evidenced that 15 always liked the meals and six usually did with two residents stating they sometimes liked the meals. The cook commented that she was aware of residents dietary needs and had information relating to any allergies. She also evidenced that a quality assurance check is carried out daily with residents being asked about the food served with comments recorded. The Poplars DS0000002465.V292336.R01.S.doc Version 5.1 Page 14 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): 16,17 The quality outcome in this area is excellent. This judgement has been made using available evidence including a visit to this service. The home takes the issue of addressing complaints very seriously and has a comprehensive complaints policy. Staff are aware of how to respond to a complaint or an adult protection allegation. EVIDENCE: Previous inspections of this home has shown that a detailed complaints procedure is in place. The homes complaints log was seen; one complaint had been received and the home informed the Commission. Evidence in the complaints log showed that this complaint has been addressed satisfactorily by the home. The complaints log has a space for complainants to sign confirming that their complaint had been addressed satisfactorily or not. Questionnaires showed that all residents were aware of how to make a complaint and knew who to speak to if they were unhappy. Two carers commented that they had undertaken safeguarding vulnerable adults training and were aware of the meaning of abusive practices. Residents response to the Commissions questionnaire showed that fourteen said staff listen and act on what they say and nine said that they did usually. The Poplars DS0000002465.V292336.R01.S.doc Version 5.1 Page 15 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): 19,26 The quality outcome in this area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well maintained, the standard of the environment and its facilities are appropriate to the needs of residents. The home is clean and free of unpleasant odours. EVIDENCE: Previous inspection have found that; the home has a maintenance record which records work that has been undertaken and projected work for the coming year. A partial inspection of the home found that new carpets with out bold patterns have been fitted in the dementia units and new lighting in all communal areas. The home employs five cleaners who are allocated designated areas to clean and tour of the home found it to be clean and had a pleasant smell throughout. Visitors stated that they have not detected any unpleasant odours during their visits. Residents responses seen in the questionnaires were unanimous in that the home is always fresh and clean. The Poplars DS0000002465.V292336.R01.S.doc Version 5.1 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): 27,28,29,30 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Appropriate recruitment practices are in place. Staffing level meets the needs of residents. The home provides adequate training for care staff. Staff were seen to be competent in carrying out their care tasks. EVIDENCE: A review of all information available prior to this inspection including the homes action plan from the inspection carried out in November 2005, showed that; all care workers have been given The General Social Care Council Codes of Practice, which sets out their responsibilities as care workers looking after vulnerable adults. Also the home now meets the ratio of 50 of the care staff trained to National Vocational Qualifications level 2. The questionnaire completed by residents/relatives showed that sixteen said that they always receive the support that they need and seven said that they usually receive the care and support that they require. Two care staff commented that there is usually enough staff on duty but they struggle during holiday periods or when there is sickness. The duty rota showed that adequate staff numbers are on duty to meet the needs of residents during the day. Since that last inspection an extra member of staff has been recruited to the night shift. The Poplars DS0000002465.V292336.R01.S.doc Version 5.1 Page 17 Carers confirmed that they undertake mandatory training as well as induction training carried out at the home and two days at Wellingore (Headquarters). The manager confirmed that Skills for Care training packs are being introduced to the home. The home also carries out appropriate checks for all new workers before they commenced work at this home. Two visitors stated that the staff are fantastic and residents are always well cared for and the home has a cheerful atmosphere. The Poplars DS0000002465.V292336.R01.S.doc Version 5.1 Page 18 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): The quality outcome in this area is excellent. This judgement has been made using available evidence including a visit to this service. 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 adhered to by all staff. EVIDENCE: The registered manager has twenty years experience at differing levels of care work before becoming the registered manager of this home five years ago. She has completed the Registered Managers Award and NVQ level 4 in care. The home conducts a six monthly quality assurance report. The July 2005 report has been made available to residents and relatives in the reception area The Poplars DS0000002465.V292336.R01.S.doc Version 5.1 Page 19 of the home. Residents meetings are held quarterly with the last meeting being on the 01/05/06. The home only deals with personal allowances of residents, which are kept safe. All other monies relating to funding are paid into the companies bank account. Two residents allowances were checked and an accurate record was kept, with two signatures and receipts available for monies spent. Two visitors stated that they deal with their relative’s finances. 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 had been serviced. All wheelchairs seen on the day of the inspection had footplates, which were in use. Two community nurses confirmed that staff were observed to use protective clothing when tending to residents intimate needs, which limits the possibility of cross inspection within the home. Two care staff confirmed that they had undertaken infection control training. The Poplars DS0000002465.V292336.R01.S.doc Version 5.1 Page 20 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 3 3 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 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 4 X X X X X x 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 4 x 3 x x 4 The Poplars DS0000002465.V292336.R01.S.doc Version 5.1 Page 21 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. Standard Regulation Requirement Timescale for action 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 DS0000002465.V292336.R01.S.doc Version 5.1 Page 22 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.V292336.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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