Inspection on 21/10/05 for The Poplars

This inspection was carried out on 21st 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Poplars 17/05/07

The Poplars 10/05/06

The Poplars 02/06/05

The Poplars 12/01/05

The Poplars 06/07/04

The Poplars 25/03/04

Similar services:

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

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

CARE HOME ADULTS 18-65 Poplars, The 889 Chester Road Erdington Birmingham B24 0BS Lead Inspector Susan Scully Unannounced Inspection 21st October 2005 09:00 Poplars, The DS0000033636.V265275.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Poplars, The DS0000033636.V265275.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Poplars, The DS0000033636.V265275.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Poplars, The Address 889 Chester Road Erdington Birmingham B24 0BS 0121 373 0288 0121 386 2460 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) Social Care and Health Elaine Crystal Miller Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Poplars, The DS0000033636.V265275.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That the home is registered to accommodate 9 adults under the age of 65 who are in need of long-term personal care for reasons of learning disability. Currently residing people who are over 65 may continue to be accommodated provided their needs can be met appropriately. The minimum staffing levels for 12 service users on weekdays when day care is off site: 7 am – 9 am 3 care assistants, 1 of whom is designated shift leader 9 am – 4 pm 3 care assistants, 1 of whom is designated shift leader 4 pm – 10 pm 4 care assistants, 1 of whom is designated shift leader 10 pm – 7 am 2 care assistants (both awake) At weekends and period without off-site day care: 7 am – 10 pm 4 care assistants 10 pm – 7 am 2 care assistants (both awake) Window frames that are in poor condition must be repaired or replaced by end of September 2004. Double-glazing and/or additional heating must be installed in the conservatory in house 837 to ensure temperature is maintained at 21oC by end April 2004. By end September 2004 plans are agreed with the NCSC with stated timescales for the future re-provision of this service to ensure standards commensurate with fitness for purpose for the needs of the client group. Re-provision to be completed by 1st April 2005. 2nd June 2005 4. 5. 6. Date of last inspection Brief Description of the Service: The Poplars is a local Authority home offering care for up to 12 adults with a learning disability. Accommodation is arranged in three houses. The Poplars has its own large frontage and rear gardens and is in an established residential area of Birmingham. The houses blend in well with other houses in the area. There are a number of local bus routes, local shops, and a railway station near by. The home is well located to access Erdington and Sutton Coldfield. The home has a total of five lounges/quite rooms. The main dining room is large and most residents use this room for their meals. The bedrooms at the home vary in size, but are all single rooms. The home has six bathrooms and seven toilets. The main house dose not have a toilet located on the ground floor. Access between the three houses is through a series of hallways and staircases and is not ideal. Poplars, The DS0000033636.V265275.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit took place over a one-day period. Records were sampled pertaining to residents, Health and Safety and Polices and Procedures. Discussions took place with residents and staff. A brief look around the building was also completed. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Poplars, The DS0000033636.V265275.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Poplars, The DS0000033636.V265275.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 Individual assessments that give sufficient detail to make a judgement as to whether The Poplars can meet the prospective residents needs must be completed. Incorporated into the assessment process information must be provided to ensure residents know The Poplars will meet their goals and aspirations. EVIDENCE: Comprehensive assessments are not completed before admission. The Poplars rely on the placing authority to complete the assessments that on occasions give very little detail. There has been no admission since the last inspection. Birmingham City Council will need to develop a format for future admission if this service is to be redeveloped. Staff at The Poplars know the residents well and based on this have identified residents needs and aspirations. Staff involve residents in drawing up of Individual Service Users Statements. Poplars, The DS0000033636.V265275.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 The personal care needs of residents are met. Staff treat each resident as an individual and work along side residents to promote their independence and autonomy. Individuals are supported to lead as active a life as possible. Arrangements are in place to minimise risk so that the safety and welfare of residents are promoted. Risk assessment are completed and updated as required. EVIDENCE: Individual Service Users Statements have been updated since the last inspection in full consultation with the residents. Comprehensive records are maintained. Care plans were sampled that gave sufficient information for staff to meet the individual needs of each resident. Staff spoken to had a good understanding of the care needs of the residents they were supporting and understood their role in the reviewing and up dating of plans. One resident said he was very happy in the way the staff supported him and he was involved in the development of person centre planning. Records sampled indicated staff were implementing his wishes. Risk assessments have been up dated since the last inspection and include monitoring and evaluation. Poplars, The DS0000033636.V265275.R01.S.doc Version 5.0 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Residents are fully consulted about Social and Recreational activities, because participation depends on the interest and ability of the resident. A nutritional meal is provided with choice and flexibility. EVIDENCE: The routine at The Poplars is flexible, where choice and freedom of movement is an every day part of life. During the day, staff were respectful to residents and consulted with them appropriately. An interaction between staff and residents was positive. Regular meetings are held with residents to enable them to air their views. The minutes of two meetings were sampled, both contained information that showed residents were involved in the local community such as clubs, day centres and colleges. Residents were consulted verbally about their likes and dislikes. The menu available showed what residents had chosen for that week, with an alternative available. Poplars, The DS0000033636.V265275.R01.S.doc Version 5.0 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 Staff are aware of what information must be passed on to other healthcare professional that may affect the type of care required. These include the residents’ medical condition together with any relevant social circumstances. All staff that administers medication must receive the relevant training in the Safe Handling and Administration of medication. EVIDENCE: Individual plans of care contained information pertaining to resident’s health care. Doctors, nurses and other professionals are consulted if the need arises. Information of appointments with chiropodists and dentist were recorded. Medication records sampled indicated a satisfactory standard of recording was maintained. Staff spoken to understood the medication policy and were able to give examples of how they implement the practice. Not all staff have received training in the safe handling, administration, and storages of medication. Poplars, The DS0000033636.V265275.R01.S.doc Version 5.0 Page 11 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Policies and procedures ensure residents are safeguarded from abuse or harm. Not all staff has received training in Adult Protection and this must be completed. EVIDENCE: The Poplars operate in line with the Birmingham Multi-Agency Guidelines including whistle blowing. Not all staff have received training in Adult Protection and this was evident when speaking with staff. Staff said if they were in any doubt they would consult the procedure within the home. Poplars, The DS0000033636.V265275.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Residents are made comfortable, with their own personal possessions. The building is not suitable for its stated purpose and discussion are taking place for the redevelopment of this service. Infection control is not maintained in the main kitchen and significant improvements must be made. EVIDENCE: The Poplars is set in three houses, all three were clean and fresh. Decoration had been completed to the external front of the building. A tour of the building was not completed at this visit. Records pertaining to clinical waste were up to date. Consultation is ongoing for the re development of this service. Concerns were raised with the Acting Manager regarding the cleanness of the main kitchen. Inside the microwave, food particles that had been there for sometime had stuck to the top of the microwave. The cooker had a large amount of grease inside and surrounding the cooker area. The grill had burnt food that had not been cleaned. Inside the oven, food that had stuck to the inside of the oven had burnt over a period of time. When the cleaning rota was sampled all the above had been signed for saying they had been cleaned. When the inspector spoke with staff as to why the rota had been signed but the work not completed. One member of staff said it makes life easier if you just sign to say Poplars, The DS0000033636.V265275.R01.S.doc Version 5.0 Page 13 it has been done. The inspector spoke with the supervisor regarding the kitchen and what action will be taken against staff for falsifying records. The supervisor said “ I will speak with staff and contact you direct with my finding and the action I have taken’’. At the time of writing this report, no notification had been received at the Commission. The Acting Manager and Supervisor must forward an action plan to the commission detailing what action has been taken. Poplars, The DS0000033636.V265275.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 35, 36 Recruitment records are not available in the home to complete an adequate audit. Training has not been completed in all mandatory areas to ensure that all staff has the relevant skills and competence to the work they perform. Nomination forms have been submitted. Supervision has commenced on a regular basis however the Acting Manager is not fully up to date with all staff. EVIDENCE: The Acting Manager said Birmingham City Council operate a robust recruitment procedure. Records are not available in the home and are held at the head office. It is a requirement that all recruitment records be available for inspection in the home. The Acting Manager has implemented a system were the training needs of staff can be monitored. Not all records are up to date. The Acting Manager has been active in seeking the views of staff and nominating staff to the training department of Birmingham City Council. The supervision records of staff indicated supervision has commenced on a regular basis. Not all staff have received supervision and the Acting manager is actively taking steps to resolve this issue. Poplars, The DS0000033636.V265275.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38, 41, 42 Residents were seen to interact positively with staff and observation made indicated residents were relaxed and comfortable in their surroundings. Health and Safety of residents is protected by the homes policies and procedure. EVIDENCE: The manager position is vacant. An Acting Manager is responsible for the running of the home and the implementation of policies, procedure and the well-being of residents. Birmingham City Council must recruit a manager to ensure a consistent service. One resident said he was very happy and staff looked after him well. Interaction between resident and staff was positive. Observations made indicated the staff and residents had a good rapport. Staff were seen to consult with resident about their daily routine and what activities they were participating in on the day of the visit. An open door policy exists and resident were seen coming into the office and speaking freely with staff about the Poplars, The DS0000033636.V265275.R01.S.doc Version 5.0 Page 16 home, lunch, and if they were going out for the day. Policies and procedure were seen including Medication, Adult Protection and Confidentiality. Records pertaining to fire, maintenance of Electrical Appliances and Gas Safety was seen and up to date. Poplars, The DS0000033636.V265275.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 2 2 X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 1 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Poplars, The Score X 3 2 X Standard No 37 38 39 40 41 42 43 Score X 3 X X 3 3 X DS0000033636.V265275.R01.S.doc Version 5.0 Page 18 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 YA2 Regulation Requirement Timescale for action 01/01/06 2 YA5 3 4 YA20 YA23 5 YA24 6 YA27 7 YA30 14(1)(a,b,c,) A complete needs assessment must be completed for all new admissions. Previous time scale 01/03/05 Non Compliance. 5(1)(c) All residents must have a contract of terms and condition of residency. Previous time scale 01/03/05 Non Compliance. 13(2) All staff must receive training in the Safe Handling and administration of mediation. 18(1)(c,i) All staff must receive appropriate training to the work they perform. Adult Protection training must be completed for all staff. 23(2)(c) A maintenance programme must be developed for the ongoing repairs of the building giving time scales for completion. Previous time scale 01/03/05 Non Compliance. 23(2)(d) Bathrooms and toilets must be redecorated to make them less institutional in appearance. Compliance not assessed. 13(4)(c) Effective infection control must DS0000033636.V265275.R01.S.doc 01/01/06 01/01/06 01/01/06 01/01/06 01/01/06 01/01/06 Page 19 Poplars, The Version 5.0 8 YA34 17(2)(b) Sch 4 18(1)(c,i) 9 YA35 10 YA36 18(2) 11 YA38 18(1)(a) 13(4)(c) be maintained. Records must not be completed unless the work has been carried out. Records pertaining to the recruitment of staff must be available for inspection in the home. Staff must complete training in Manual Handling, Fire Safety, Food Hygiene, NVQ Level 2 or above. Previous time scale 01/03/05 Non Compliance. All staff must be appropriately supervised at least six times per year and a record of this retained. Previous time scale 01/03/05 Non Compliance. The Responsible Individual must recruit a registered manager for this service. 01/01/06 01/01/06 01/01/06 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Poplars, The DS0000033636.V265275.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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