Inspection on 25/04/07 for The Poplars

This inspection was carried out on 25th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Poplars 07/11/05

The Poplars 10/05/05

The Poplars 27/01/05

The Poplars 24/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Poplars (The) 1 Station Road Whitwell Derbyshire S80 4TD Lead Inspector Tony Barker Unannounced Inspection 25th April 2007 09:40 Poplars (The) DS0000020076.V329386.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 Poplars (The) DS0000020076.V329386.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. Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Poplars (The) Address 1 Station Road Whitwell Derbyshire S80 4TD (01909) 722244 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) Nottingham Regional Society for Adults and Children with Autism (NoRSACA) Mr Kevin Michael Pakenham Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2005 Brief Description of the Service: The Poplars care home is situated in a quiet residential cul de sac near the centre of Whitwell. The home is a brick built bungalow in a residential area with a secure private garden. All residents are accommodated in single rooms. The home is registered as a care home to provide personal care for up to 5 adults with learning disabilities aged 18 to 65 years. The home specialises in providing care for adults with Autism. The fees are currently £1003 per week. Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 8.25 hours and was a key unannounced inspection. The service users had high levels of dependency and therefore were not able to contribute directly to the inspection process, though they were observed working with and being cared for by staff. Survey forms were posted to all five service users and four were returned. Key workers had helped service users complete these. The information supplied in this way was analysed before the inspection and the outcomes included in the inspection process and reflected in this report. The Manager and one residential social worker were spoken to and records were inspected. There was also a tour of the premises. Two service users were case tracked so as to determine the quality of service from their perspective. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. The pre-inspection questionnaire was reviewed prior to this inspection. What the service does well: What has improved since the last inspection? The quality of care plans had improved and the frequency of reviews. The administrations of medicines was being accurately recorded and staff training and supervision had improved. Health and safety issues had been addressed. Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 6 Thirteen of the fourteen requirements and all of the six recommendations made at the last inspection had been met. 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 summary of this inspection report can be made available in other formats on request. Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 7 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) DS0000020076.V329386.R01.S.doc Version 5.2 Page 8 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): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual written needs assessments were in place before people were admitted to the Home so that their diverse needs were identified and planned for. EVIDENCE: The Statement of Purpose had been revised in April 2006 and was a satisfactory document. A range of additional information was available including a comprehensive information book for parents and a picture brochure for service users. The picture brochure had been improved to include information on how to make a complaint and service users had been surveyed about their views of the Home. Service users confirmed, in the postal survey, that they had enough information about the Home before moving in so they could decide if it was the right place for them. One service user stated, “I came for meals and visited at night and the weekend”. There had been no new admissions to the Home since the previous inspection. At that time it had been noted that multi agency assessment and consultation with families occurred prior to placements being offered at the Home. Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 9 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 good. This judgement has been made using available evidence including a visit to this service. Service users had an individual plan of care which indicated that they were treated as individuals and their personal goals were being considered. EVIDENCE: The care plans of two case tracked service users were examined. These were well recorded, with each service user’s needs being accompanied by an action plan. Service users’ preferences were being recorded and new records had been introduced that included ‘Personal Development Plans’ and itemising individuals’ ‘strengths’. There was further evidence of a ‘person centred approach’ being taken - particularly with respect to one case tracked service user whose wishes and interests were being identified through meetings of the person’s ‘Circle of Support’ – a circle of people important to the service user. Several meetings of these people, together with the service user, had taken place. The minutes of these meetings were not being held within the Home and there was no evidence of linking the outcome of these meetings with other records in the Home’s care planning system. The wording of the ‘Personal Development Plans’ was constructive and person centred. However, one particular care planning document included reference to ‘Inappropriate Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 10 Behaviour’, which is not person centred wording as it reflects the viewpoint of the service rather than the individual. Care plan documents were being reviewed every six months, as required at the previous inspection. The Manager spoke of introducing six-monthly care planning review meetings in respect of each service user, when their social workers were arranging review meetings once a year. The residential social worker, who was spoken to, gave examples of service users making decisions and choices. She said that two or three service users choose their weekend and evening activities and one case tracked service user has chosen the member of staff to accompany the person on an overseas holiday, later this year, to visit close relatives. Service users confirmed, in the postal survey, that they generally could do what they wanted during the day and weekends. Recorded risk assessments were in place, reflecting consideration being given to a range of dangers to which service users could be exposed and ways of minimising these dangers. The residential social worker confirmed that service users benefit from taking risks when, for instance, they undertake a new activity or one they previously had found too traumatic. Examples of the latter showed how service users were developing their confidence in social situations and how their quality of life was improving. The Manager explained that he had received training on introducing service users to taking ‘responsible risks’. This training had been shared with staff at a staff meeting and had preceded the decision to consider an overseas flight for one service user, with staff support. Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 11 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 good. This judgement has been made using available evidence including a visit to this service. The Home provided activities and services that were age-appropriate and valued by service users and promoted their independence. EVIDENCE: The Manager described tangible evidence of the success of the ‘Circle of Support’ meetings, for the personal development of the case tracked service user mentioned in Standard 6. He said that the meetings had identified the service user’s wish to fly to Edinburgh on holiday. This was the service user’s first experience of flying and described it, in the postal survey, that “it was just like a train in the sky”. The Manager said that the holiday “really brought (the service user) out” and that the person was able to express themselves where previously they had been unable. A flight to Australia was being planned for this service user later this year (see Standard 15). Other aspects of standard 11 were not assessed on this occasion. Each service user was attending structured day services four days a week, with the fifth day each week spent with their key worker building their independent Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 12 living skills. On that day they undertook household tasks and activities in the community. The residential social worker, who was spoken to, provided evidence of service users taking part in valued and fulfilling activities that were appropriate for their age and gender. These included trips to the swimming pool, ‘cook and eat’ sessions and ‘make up’ sessions for the female service users. She said that their body language makes it clear how enjoyable they find an activity. The residential social worker described positive interactions between service users and members of the public, usually during the day a week spent with their key worker. Local community services used by service users include shops, cafés, pubs, barbers and the swimming pool. The residential social worker said a number of local people know, and use, service users’ names. There was good family contact for all the service users, with some spending time on leave with their families on a regular basis. One service user stated in the postal survey that, “My parents come and see me regularly every other week”. Another service user had close relatives living in Australia and efforts were being made to improve contact through e-mails and a ‘web cam’. A flight to Australia was being planned for later this year. Families were involved at care plan review meetings and were well represented on the Company’s Management Committee. Service users also occasionally had an evening meal with day service friends, the residential social worker said. The Home is commended on its focus on maintaining family links and friendships. The residential social worker provided evidence of daily routines being flexible. During ‘Independent Living Skill’ days routines such as meal times are adjusted according to activities being undertaken and service users’ wishes. She spoke of service users choosing their clothes and their shoes, with guidance from staff, and male service users who choose between wet and dry shaves. All service users were involved in domestic activities and they participated in shopping for food for the Home. All bedrooms had door locks that service users could choose whether or not to have activated. The residential social worker stated that staff knock on bedroom and bathroom doors before entering and doors are kept shut while service users are in these rooms. Foodstock levels in the kitchen were good and included fresh fruit and vegetables. The residential social worker said that healthy eating is encouraged. The main meal of the day was seen served up, on the day of this inspection: good-sized portions were noted. Weekly menus indicated that service users were receiving a nutritious and balanced diet. However, there were no daily menus displayed that would inform service users and reduce the need to ask staff. The residential social worker said that service users may choose an alternative meal if they are known to dislike an item on the menu – which itself had been drawn up from knowledge of individuals’ likes and Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 13 dislikes. She said all service users were involved in food shopping at some time. Care plans included lists of service users’ food likes and dislikes. Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. The Home was providing service users with personal support in the way they preferred and required and was meeting their health needs in an individualised way. EVIDENCE: There was evidence of service users’ communication needs being well addressed. For instance, a communication book had been developed for one service user together with the local Speech and Language Team. This enabled the service user to point at photographs of snacks and activities that reflected the person’s wishes. Additionally, a ‘All about my Communication’ document had been drawn up by this service user’s key worker, with help from a speech and language therapist. This document took a very person-centred approach. The Manager said that staff will leave some service users to ‘take a soak’ in the bath on their own. The benefits of this to individual service users, and the potential risks, had been considered but there were no documented risk assessments to reflect these actions. There was an ‘intercom’ in one bedroom so that staff could monitor the service user’s epilepsy during the night. This arrangement could be considered intrusive and the use of alternative measures was discussed with the Manager – a pressure mat by the service user’s bed, for example. Overall, there was evidence of staff supporting service users to maximise control over their lives. Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 15 There was a good system for recording service users’ individual appointments with health professionals and the action taken on these occasions. The residential social worker spoke of contacts with a chiropodist, speech and language therapists and consultant psychiatrist, adding that service users were quite healthy. The Manager said he had had asked the local surgery about setting up a ‘well-woman’ clinic and ‘well-man’ clinic and was hopeful about the former. He also spoke of planning the introduction of Health Action Plans as part of service users’ care plans. These were a way of individualising service users’ health needs, as part of person centred planning, with involvement from Primary Care Trusts (PCTs). Medication Administration Record (MAR) sheets were typed, where previously they had been handwritten. Service users photographs were filed with these MAR sheets and there was a sheet of specimen staff signatures/initials providing further evidence of good practice. Any handwritten entries were signed and countersigned. The Manager explained that medicines were no longer being sent to day services with service users – the times of administration had been adjusted to make this unnecessary. This action had reduced the potential for mistakes being made. The Home had obtained an up to date drug reference book and was recording the date of opening topical preparations, as required at the previous inspection. There was no recorded rationale for the administration of ‘as and when required’ (prn) medication – setting out the circumstances when this medication should be administered. Otherwise, the procedure for the use of prn medication was safe, with manager approval being needed before administration. Before the end of this inspection the Manager had started to formulate a recorded rationale. Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 16 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. There was a robust complaints procedure and good staff awareness regarding safeguarding adults so that residents felt safe and were protected from abuse. EVIDENCE: There had been no formal complaints about the Home received since the last inspection, or at any time, the Manager reported. A copy of the Home’s complaints procedure was displayed in the rear entrance hall and contained the Commission for Social Care Inspection’s address. However, it still made reference to the National Care Standards Commission. Another copy of the complaints procedure was displayed in the activity room and this was accompanied by symbols so that service users could understand it. The form, on which formal complaints could be recorded, was of a good design. There was no system for recording more minor concerns expressed, or experienced, by service users. Service users confirmed, in the postal survey, that they knew how to make a complaint and who to speak to if they were not happy. Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 17 The Manager stated that four of the six care staff had been provided with training on keeping adults safe from abuse. The residential social worker confirmed she had received this training and showed awareness of the Home’s ‘Whistle Blowing’ policy. She, and other staff, had also received their own copy of this policy, within a staff manual. The Home had a satisfactory written policy on responding to incidents of abuse. The Manager explained that all incidents, of staff physically restraining service users, were recorded, mostly taking the form of a brief holding of a service user’s hands or arms. Two of these records were examined and, in the Inspector’s opinion, they contained inadequate details concerning the location within the Home, the duration of the actual restraint and the name of the staff member restraining. Records of service users’ monies were checked and it was noted that all transactions had double signatures to verify them, as recommended at the previous inspection. Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 18 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 good. This judgement has been made using available evidence including a visit to this service. Service users were living in a safe, hygienic and well-maintained environment, which was furnished and decorated to a good standard. EVIDENCE: The Home was being maintained to a good standard and was homely in appearance. Furniture and decoration were in good condition. The Home had been redecorated since the previous inspection and six new dining chairs purchased as well as a reclining easy chair in the conservatory. The bedrooms of the two case tracked service users were examined and these were very comfortable and personalised. The two service users appeared relaxed and happy to ‘show off’ their rooms. In the bathroom the bath panel was split in places and the floor covering was in need of attention. The Manager explained that the floor covering would be replaced as part of a proposed extension to this room. There were two one-way bolts fitted on each side of the door to the toilet by the activities room. These were pointed out the Manager as potentially putting service users at risk and he removed them both on the day of the inspection. The garden was in a reasonable condition and new screening had been erected at the rear of the Home to obscure the washing lines. Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 19 The laundry room contained a washing machine and dryer. Although dirty washing was usually carried through the kitchen to the laundry room the Manager assured the Inspector that an alternative route existed for the occasional heavily soiled clothing or bedding. The Manager spoke of plans to create a new laundry room as part of a proposed extension to the premises. There were no continence management issues within the Home and no unpleasant odours were apparent at the time of this inspection. The Home was clean and hygienic and the services users confirmed, in the postal surveys, that the Home was fresh and clean. Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 20 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 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home had a stable group of well-trained and supervised staff to ensure that service users’ needs were appropriately met. EVIDENCE: All of the 6 care staff had achieved a National Vocational Qualification (NVQ) to level 2 or above. This fully met the National Minimum Standard to maintain a staff group with at least 50 qualified staff, and is commendable. There had been a very stable staff group at the Home for some time and no staff turnover since the previous inspection. One of the April staffing rotas, sent with the returned pre-inspection questionnaire, was examined. From discussion with the Manager it became clear that it did not reflect all his hours and it was therefore not possible to fully assess the adequacy of hours against the Residential Forum’s formula for calculating minimum staffing hours. The Manager was informed of this. At the previous inspection, staff personnel files had been examined and found to contain all the required checks to ensure staff were suitably employed to work with vulnerable service users. As there had been no additional staff since that inspection this Standard was not reassessed. Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 21 The Manager stated that all staff had been provided with mandatory training except for some who last undertook moving and handling training more than three years ago. There was an ’at a glance’ training matrix available that confirmed this. The residential social worker who was spoken to confirmed she had attended a range of mandatory training courses over the two years in this employment. She also confirmed she had followed induction and foundation training that meets the specifications laid down by ‘Skills for Care’. Staff were additionally attending a range of training courses specific to the specialist needs of service users. The Manager confirmed that formal one to one supervision was being provided to staff at the required intervals. These sessions included staff appraisals in February 2007. Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 22 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): 37,38,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home was well managed so that service users were protected and their best interests were promoted by the systems in place. EVIDENCE: The Manager had achieved the Registered Manager’s Award at National Vocational Qualification (NVQ) level 4 and had worked with people with autism for 19 years. He had also achieved other awards including that of a Licensed trainer with City and Guilds. Positive comments were made by two residential social workers about the Manager’s skills. One of these workers gave further details about the level of job satisfaction she experiences and commented that, “We get on well together as a team”. Details of designated duties for staff were attached to the preinspection questionnaire indicating the degree to which staff were enabled to affect the way in which the service is delivered. Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 23 Records of the monthly, unannounced audit visits to the Home, undertaken on behalf of the registered provider, were examined and found to be satisfactory. The Manager stated that the Company had a three-year plan for its overall services and this makes reference to The Poplars in terms of budgetary expenditure. However, there was no annual development plan specifically for the Home, based on a systematic cycle of planning-action-review. The Manager spoke of ‘The Quality Network’ operating at the Home whereby a sample of service users are visited and their quality of life assessed. As part of this assessment service users’ parents are interviewed, he explained. Also, staff who leave the Company’s employment are asked to complete an ‘exit questionnaire’. The Manager confirmed that the Home’s quality assurance measures did not include surveying the opinions of current staff and of external professionals. The Home’s Fire Alarm procedure was displayed in the activity room and this was accompanied by symbols so that service users could understand it. Monthly fire drills were being undertaken and a record of weekly fire alarm tests was seen. The Manager reported that the contents of the First Aid cabinet had been reviewed since the previous inspection and were checked monthly by one designated staff member. A replacement refrigerator and a fly screen had been purchased following recommendations from the Environmental Health Officer at his last visit. Working temperatures of the refrigerators and freezers were being recorded daily. Cleaning materials were being safely stored. There were written risk assessments for the Home’s environment and the pre-inspection questionnaire showed that equipment was being checked and maintained appropriately. Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 24 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 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? 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 YA35 Regulation 14.8 Requirement Refresher training in moving and handling must be provided for all staff that work with service users who have been assessed as potentially having difficulty in moving themselves. (Outstanding from inspection dated 7/11/05) Timescale for action 01/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA6 YA17 Good Practice Recommendations A copy of the minutes of ‘Circle of Support’ meetings should be held within the Home and these records should form part of the Home’s individual care planning system. Daily menus should be displayed, in a form understandable to service users – using photographs of plated meals, for example. The practice of service users ‘taking a soak’ in the bath should be reflected in a recorded risk assessment. There should a multi-professional review of the arrangements, within one bedroom, to monitor the service user’s epilepsy during the night. DS0000020076.V329386.R01.S.doc Version 5.2 Page 26 YA18 YA18 Poplars (The) 5. YA20 6. 7. 8. YA22 YA22 YA23 9. 10. 11. 12. YA24 YA33 YA39 YA39 A rationale should be recorded for the administration of ‘as and when required’ (prn) medication – setting out the circumstances when this medication should be administered. The Home’s written complaints procedure should make reference to the Commission for Social Care Inspection. A system for recording more minor concerns expressed, or experienced, by service users, should be considered. Records, of staff physically restraining service users, should contain more explicit details concerning the location within the Home, the duration of the actual restraint and the name of the staff member restraining. The split bath panel should be replaced. The Home should maintain an accurate staffing rota that includes the Manager’s hours and takes account of the Residential Forum’s staffing formula. An annual development plan for the Home should be created. The Home’s quality assurance measures should include surveying the opinions of current staff and of external professionals. Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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. Extracts may not be used or reproduced without the express permission of CSCI Poplars (The) DS0000020076.V329386.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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