Inspection on 26/06/08 for The Poplars

This inspection was carried out on 26th June 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Poplars 20/07/07

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 27/02/2009.

CARE HOME ADULTS 18-65 Poplars, The 225 The Poplars Arbury Road Nuneaton Warwickshire CV10 7NE Lead Inspector Julie McGarry Announced Inspection 26th June and 23 July 2008 08:00 rd Poplars, The DS0000068557.V366858.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 DS0000068557.V366858.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 DS0000068557.V366858.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Poplars, The Address 225 The Poplars Arbury Road Nuneaton Warwickshire CV10 7NE 0247 6370415 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) Coventry and Warwickshire Partnership Trust Mrs Audrey Alldrick Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can provide care and accommodation for 4 service users under the age of 65 for reasons of learning disability. 20th July 2007 Date of last inspection Brief Description of the Service: The Poplars is registered as a care home that provides accommodation and care for four adults, aged 18 - 65 years, with learning and physical disabilities. The home has recently reregistered under Coventry and Warwickshire Partnership Trust and is staffed 24 hours a day. The building is modern, single storey and purpose-built, set in a small close just off a main road. There is an entrance lobby and hallway, kitchen, utility room, large bathroom, staff sleeping room/office, four service users bedrooms and an integral lounge/dining room. There is an adequate sized garden with a patio area and furniture that is accessed through doors leading from the lounge/dining room. The home is within walking distance of local shops. Nuneaton town centre is approximately 2 miles away. A regular bus service provides access to the town centre and local railway station. The home has a vehicle, adapted to meet the needs of wheelchair users for transporting residents to various activities. Coventry and Warwickshire Primary Care Trust (NWPCT) provides service users with all personal care services including day care. Information regarding funding was not available for this inspection. Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1star. This means the people who use this service experience adequate quality outcomes. This Key Inspection was unannounced; it was undertaken over two days on the 26th June and 23rd July. The inspection was stopped early on the first day as one person who had lived at the home for seven years died. This inspection was carried out to establish the outcomes for people living in the home, and to confirm whether they are protected from harm. The pre fieldwork inspection record was completed, as well as a site visit to the home, during which time staff, people living in the home and the manager were spoken with. A completed annual quality assurance assessment was received from the service prior to the inspection along with 3 surveys completed by the people who live there. Due to the communication needs of the people who live at this home, the surveys were completed with support from staff. The people who live at this home have communication needs and rely on staff support to recognise and respond to their needs and wishes. The manager was present throughout the inspection. At the time of the last inspection there was a manager in post, however he was off work ill and the team leader was running the service. The home now has a new permanent manager in position. The manager took up this position on the 16th June 2008. Policies, procedures and care records were examined. Staff records, environmental checks and risk assessments were also read. During the inspection, the care of two people who live in the home was examined in detail. This included, reading assessments, care plans, and other documentation, observing care offered to them and that staff have necessary skills to care for them. This is part of a process known as ‘case tracking’. Where evidence is matched to outcomes for the people who live in the home. Specific elements of one other person’s care were also looked at to see if the outcomes are good. The inspector ate lunch with people who live in the home in the lounge, and was able to observe practices, and how staff interacted with individuals. The inspector would like to thank the manager, staff and the people who live at The Poplars. Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Since the last inspection the home has a new manager who is currently registering with us. Work has been undertaken to redecorate areas of the home. The lounge/ dining room and all four bedrooms have been redecorated since the last inspection Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 7 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 DS0000068557.V366858.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have the information needed to decide if the home can meet their needs. They have their needs assessed and a contract that clearly tells them about the service they will receive. EVIDENCE: The home has a Service User Guide and Statement of Purpose in place. As identified at the last inspection, the Statement of Purpose would benefit from being updated as this currently contains details of the previous manager and outdated Commission For Social Care Inspection details. Information about the weekly fees and other charges should be included in the Service User Guide. There is currently one vacancy at the home. Staff are looking at how make best use of the room that has recently become available. Staff are liaising with the Commissioners at the Primary Care Trust to discuss how the available room will be used in the future. Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 10 Two files of people who live at the home were viewed and both contained contracts for their stay there. The contracts were available in easy read format. The home does not have any male care staff. This means that male residents do not have the option of having care provided by a man. As no new people have moved to live at The Poplars since the last inspection, the pre assessment process was not examined as part of this inspection. Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The outcomes for people who use this service are good and people are supported to make everyday choices so that they can exercise some control over their daily lives. Care plans and risk assessments are not always completed in detail to describe people’s individual needs to ensure that they receive the care and support that they require in a consistent manner. EVIDENCE: Care plans of two residents were examined. Some elements of these were good in providing detailed guidelines for staff in supporting residents and the home uses a person centred planning approach with aspects of the care plans. Further work must be undertaken to ensure documents are completed in full and dated to ensure records evidence needs are current and are being Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 12 appropriately managed. For example, one of the people we looked at did not have a risk assessment on the need for bed rails and absence of bumpers. This was brought to the manager’s attention and she arranged for a risk assessment to be carried out and a copy of this was given to the inspector on the day of the inspection. Another file was missing up to date guidance to help staff to manage behavioural challenges sensitively that link to infection control matters in the kitchen area. These shortfalls in information could lead to new staff not meeting people’s needs properly. No care plans examined had been reviewed in twelve months despite health records showing changes to people’s needs. Comments by staff and the manager demonstrated a more detailed knowledge of people’s care needs and the care provided than is recorded in the care plans. They were able to illustrate good care practices. For example staff were able to give examples of the safe practices they follow to ensure that people are supported when eating and of the procedures they would follow to support one person at meal times following his recent assessment by consultant regarding his dietary needs. Similarly staff were able to explain the sensitive approaches they would follow to support a person who presents behaviours in relation to risk to infection control in the kitchen area. Each person living at the home has a key worker. The people who live at the home are involved in the planning of their care through Key worker meetings. These meetings have recently started and the manager informs that Care Plans will be reviewed in line with the outcomes from the key worker meetings. From discussions with staff and peoples care plans, it was evident that people are encouraged to maintain and develop their independence. On the day of the inspection all three people at the home were supported to go shopping to buy personal items and food for the home. Staff hold meetings with the people who live there every Monday and Friday to make decisions about menu choices and activities preferences. Care plans and daily records also detail information on promoting peoples independent living skills through such activities as planned cooking sessions. Due to the physical needs of the people who live there, they require staff support to make any meals / snacks. It was seen on the inspection that staff understood when residents were indicating that they wanted something and staff responded in a timely and respectful way. Staff were observed offering choices to the people who live there. The people who live here have communication difficulties. Staff were observed communicating with the people who use the service effectively and respectfully. Care plans detail information to guide staff how to communicate Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 13 with the people who live there in their preferred styles. For example, one person who does not use a recognised sign language has developed their own means of telling staff what they want through different signals. Staff were seen to understand and respond to the needs of that individual. Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to make choices about their life style, and supported to develop life skills. Social, educational, and recreational activities meet individuals’ expectations. EVIDENCE: Activity planners were seen in individual care plans and showed that people do different things each day either in small groups or on a 1:1 basis with staff. From looking at the information in the care plans of the two people “case tracked” it was evident that the activity planners reflected individual preferences. Daily records were looked at which showed that people had access to a range of activities such as going out to places of interest, including the shopping, bowling, going out for pub meals, and to such places as Stratford Butterfly Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 15 Farm. We were told that people had planned to go to Kingsbury Park for a picnic this Friday, weather permitting. Mealtimes are relaxed and unhurried. A lunchtime meal was observed and staff were seen to sit with residents and give assistance where needed in such a way that maintained the resident’s dignity and safety. The lunchtime meals were very well presented and appeared appetizing. Menus and records of food consumed by individuals were sampled to establish that a balanced and varied diet is provided that meets peoples’ needs and preferences. A range of food had been offered including Sunday roasts and other traditional English dishes that reflect the cultural needs of people living in the home. Some of the people maintain links with their family. There was evidence in daily records that people’s needs with regard to keeping in touch with friends and relatives had been recorded. The service manager informed that staff helped one person to trace their relatives, and the outcome was that person was able to locate and visit their mother’s grave. Records showed that another person was able to spend time away from the home with family members. Staff took photographs and have been putting photograph albums together for that individual to help them remember their family visits. Staff have recorded individuals religious preferences. There are no records to show how people are supported to practice their chosen faith. The manager informs that the staff have recently contacted the local Roman Catholic Church to make arrangements for one persons religious needs to be met. Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 21. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Records that describe individual’s health and medication needs are not always completed in detail to describe how those needs should be met, however staff have a good understanding of how to offer care and support to each person. EVIDENCE: Residents were all smart in their appearance, their clothes were clean and fresh and appropriate to their individual lifestyle and needs. Staff told us that they are aware of the need to protect people’s privacy and dignity when supporting them with personal care. However, on the day of the inspection staff told us that due to the size of the bedrooms, staff need to leave the bedroom door open to safely manoeuvre equipment when personal care is being provided. This situation was discussed, and staff arranged for a mobile curtain rail to be brought to the home to use when personal care is being provided. This provides greater privacy to those who are receiving support in their rooms should the door need to remain open. Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 17 Residents receive personal support in the way they prefer and require as evidenced through observations during the inspection, discussions with staff and examination of records. For example, on each morning of the visits not all residents were up and dressed when we arrived at 8:30am. Residents arose at varying times and were supported to the dining room when they felt ready for breakfast. As at previous inspections, health records looked at continued to evidence that people have ready access to a GP and other health professionals locally including, consultants, dentists, speech and language therapists, opticians and chiropodists. The information in the care plans are not well organised and could lead to new staff being ill informed about how people’s care support is to be provided. However discussions with existing staff and the manager illustrated that staff are providing good care and sensitive support and have a good understanding of people’s needs. No care plans have been reviewed in approximately twelve months despite recent information from dietician about a need to change care practices for one person. Additionally, there is no information on how staff were providing support and monitoring people’s needs following their recent loss of one person who lived at the home. A suitable lockable cabinet is in place for the safe storage of medication at the home. The cabinet was well ordered and not overstocked. However there were creams/ ointments in a storage cupboard that is located near the boiler. Creams have labels clearly stating that they should be stored below 25 degrees. Temperatures of storeroom are not monitored and on the day of the inspection, the room felt warm raising concerns that the temperature was higher that 25 degrees. This could impact upon the effectiveness of the creams / ointments. The pharmacist delivers medication in blister packs. The medication sheets show that the number of tablets received into the home so that they can be accounted for and that staff are signing for the medication given out. The audit trail shows that there was a possible medication error by staff or the pharmacist, which leads back to before January 2008. This error continues to have a knock on effect of the tally of medication for one person as the records show that they are two tablets short at the start of each month. The manager has agreed to look into this and discuss with the pharmacist to ensure that records are up to date and not short at the start of each month. We also noted one recording error and omissions that had not been identified by staff at the home in the audit records. Audit records for two individuals showed that staff did not record on two occasions when one particular medication was administered, however the medication sheets were correct. Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 18 The home currently carries no controlled drugs that would necessitate any special storage and recording arrangements. There are no drugs that need to be stored in the fridge. There are a range of policies and procedures in place relating to administration, covert practices, training and disposal of medication in each individual’s medication folder. The inspection was stopped early into the first day as one person who had lived at the home for seven years died. The inspector observed staff responding to and dealing with this in a calm and dignified manner. Staff ensured the other people who live at the home continued to receive the support and care they required. A number of staff and the three people who live at the home attended and participated in the funeral. The home had clear guidelines in the care plans for this person in relation to end of life care and funeral arrangements. Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 19 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 are appropriate procedures in place to listen and respond to peoples’ concerns and complaints and safeguard them from the risk of harm. EVIDENCE: The annual quality assurance assessment and records seen during this visit showed that there had been no complaints made about the home since the last inspection. The home received and responded to one compliant received on the day of the inspection in relation to car parking at the front of the building. This was dealt with appropriately and recorded in the complaints log. There is an accessible complaints procedure ‘Letting us know’ in place at the home with pictures to help people to understand the contents. The complaints procedure is contained in people’s files and Service User Guide. Staff development records showed that the majority of staff had completed National Vocational Qualifications (NVQ) or Learning Disability Award Framework (LDAF) training, which includes sessions in safeguarding vulnerable adults. The home has a safeguarding policy in place. Two staff on duty confirmed that they had seen the Safeguarding procedures and one said they had been provided with training and the other received training at a previous job but not at this service. A training certificate was seen in one staff file as Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 20 verification of this. The people who live there would benefit from all staff being trained and informed of complaints procedures and safeguarding procedures. There have been no safeguarding concerns at the home since the last inspection. The manager is currently looking into a concern raised by a member of staff. This is being dealt through the homes own internal procedures. Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 21 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, 26, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a clean, safe and comfortable environment that meets their individual needs. EVIDENCE: The Poplars is a modern, single storey and purpose-built building, set in a small close just off a main road near Nuneaton town centre. There is an adequate sized garden with a patio area and furniture that is accessed through doors leading from the lounge/dining room. The home has a vehicle, adapted to meet the needs of wheelchair users for transporting residents to various activities. As previously mentioned, the bedrooms are modern and personalised. Due to peoples mobility needs special equipment is required, room sizes are not Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 22 sufficient to safely manoeuvre the equipment whilst having the bedroom door closed this can impact upon the privacy and dignity of those who live there. The home also has limited storage space. On the day of the first inspection, a chair belonging to one individual was being stored in another individual’s room due to lack of space available. Staff encounter difficulties in holding staff meetings. The office does not accommodate the staff team, and there is only one lounge, which is occupied during the day by the people who live at the home. This problem has recently been addressed as one bedroom has become available, however this may only be short-term solution. The building was clean and there were no unpleasant odours, which indicate that effective cleaning and infection control procedures are in place. Staff were observed to be wearing aprons and gloves when carrying out personal care and domestic tasks. At nighttime, there is one sleeping staff member and one waking staff member. There is no ‘sleep–in’ room, so staff sleep in the office. During the first day of the inspection, the inspector noted that a cupboard holding domestic products was unlocked. The manager ensured this was addressed immediately. This was checked on the second visit was found to be locked throughout the day. The kitchen was clean and well organised. Records were kept of the fridge and freezer temperatures showing appropriate temperatures to maintain good food safety. Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 23 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, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by a well-trained and competent team of established staff who have good understanding of their individual needs. The home operates a robust system of recruiting staff for the protection of the people who live there. EVIDENCE: It was evident from watching staff at work that they have formed meaningful relationships with the people who live at The Poplars. Three staff files were looked at to ascertain whether recruitment policies were robust. The recruitment records sampled showed that appropriate checks had been made to make sure that staff were suitably experienced and qualified to work with vulnerable adults. Criminal Records Bureau checks had been made and written references received before the employee began work so that Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 24 people were protected from the risk of having unsuitable staff work in the home with them. Until recently, staff were not receiving formal supervision. The manager has informed us that this will now become standard practice for staff. Staff confirmed that this is now happening and staff supervision notes were seen. The total number of staff within the home is twenty-two, this includes a full time manager whose hours are supernumerary, and a team leader. The majority of staff work part time. Information supplied by the manager state that 10 members of care staff are qualified to National Vocational Qualification in Care Level 2 (NVQ level 2). This is at the national Minimum Standard for 50 of staff to be qualified. This should mean that residents benefit from having their needs met by staff that are appropriately experienced and qualified. The training records of staff working at the home were seen and demonstrate that staff receive mandatory training. It was evident that staff have opportunities to attend various training programs, not all staff have attended training in safeguarding. The manger has made arrangements for staff to receive training in infection control and stoma care, which relates specifically to the needs of people who live at the home. Staff present during this visit were able to answer our questions about meeting the needs of people who live in the home and have clearly got to know them well. The home does not have any domestic or catering staff. Care staff take on these duties during their shifts. Most of the care staff are trained in food hygiene. Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being managed in a way that listens to and acts upon the views of the people who live there. The management of some areas of health and safety practice is not sufficient to ensure people are protected from potential risk of harm. EVIDENCE: At the time of the last inspection there was a manager in post however he was off work ill and the team leader was running the service. The home now has a permanent manager in position. The new manager took up this position on the 16th June 2008. The manager has completed her NVQ level 4 and registered Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 26 managers award and has previously worked within learning disability services. During conversation with her, she demonstrated a clear understanding of the way the service should continue to ensure ongoing development so that people who use this service can continue to live ordinary and meaningful lives as they grow older. It was observed that staff feel they can talk comfortably with her and discussions heard between staff and the manager were open and respectful. People who live and work at the home made positive comments about the manager, saying that they felt the team “was more cohesive” and that it “made a positive difference having a manager in post”. During this visit the office door remained open and people came in frequently to talk to her. This indicates that the manager makes herself accessible to listen to people who live and work at The Poplars. The Annual Quality Assurance Assessment (AQQA) completed by the service manager was completed to a good standard. Information provided was supported by a range of evidence, and the Annual Quality Assurance Assessment (AQAA) fully informed us about changes the home has made and where improvements still need to be made. The service manager visits The Poplars on a regular basis to report on the standard of care provided of which reports are made available within the home. From the most recent reports, minutes of meetings and discussion with the staff team, it was evident that the views of people who live in the home had been actively sought with regard to the way in which the service is being run. We were told that there are regular house meetings so that people have an opportunity to discuss issues that are important to them, such as planning activities and menus. A number of checks are made by staff to make sure that peoples’ health and safety is maintained. Records showed that the fire alarm system had been regularly tested and serviced to make sure that it was working properly. One of the two staff spoken to did not know where the fire assembly point was and had not taken part in a fire drill in the three months they had worked at the home. The staff training matrix did not specify that training in fire safety had been provided although staff did confirm that they had covered some aspects of fire safety as part of their induction. Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 X 4 X 5 3 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 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 3 2 X 3 X X 3 X Poplars, The DS0000068557.V366858.R01.S.doc Version 5.2 Page 28 No 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 YA6 Regulation 17 Requirement Each individual must have a detailed care plan to assist staff to meet all their needs. There must be risk assessments in place for all people living at the home. Care plans must be available for all identified risks. Timescale for action 31/08/08 2. YA6 13 (4) (c) 31/08/08 3. YA20 13 (2) Storage of all medicines 31/07/08 including control drugs must be in accordance with the legislation (The Royal Pharmaceutical Society). Staff drug audits need to be undertaken to ensure all medications are accounted for. Appropriate action must be taken when discrepancies are found. Medication must be administered at the prescribed dosage and at correct intervals. All staff working in the home must be trained in all areas related to Safeguarding Vulnerable Adults. This will ensure that people who use the service are protected from harm DS0000068557.V366858.R01.S.doc 4. YA20 13 (2) 31/07/08 5. YA32 13 (6) 31/08/08 Poplars, The Version 5.2 Page 29 and abuse. 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 DS0000068557.V366858.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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