Inspection on 07/11/05 for The Poplars

This inspection was carried out on 7th November 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 no outstanding requirements from the previous inspection report, but made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Poplars 25/04/07

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 Bridgette Hill Unannounced Inspection 7th November 2005 09:10 DS0000020076.V263608.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 DS0000020076.V263608.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. DS0000020076.V263608.R01.S.doc Version 5.0 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 Autistic Children and Adults Mr Kevin Michael Pakenham Care Home 5 Category(ies) of Learning disability (5) registration, with number of places DS0000020076.V263608.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th May 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. A range of day services are also provided to service users at various sites. DS0000020076.V263608.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced one which took place over 4 hours. As part of the inspection two staff members were spoken with. A sample range of records were examined including care files. This report should be read alongside the one for the inspection undertaken on 10th May 2005 where many core standards were assessed as being met. 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. DS0000020076.V263608.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 DS0000020076.V263608.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): 1 Information was available in a range of formats including a picture brochure for service users and whilst all information was available there needed to be a review of documents to ensure information was presented in the appropriate format. EVIDENCE: The Statement of purpose contained some transitional information such as the fees charged. There was not an actual document entitled Service User Guide but a range of information was available including a comprehensive information book for parents and a picture brochure for service users. It was assessed that information was available to service users and their families and there was attempts to tailor this to the needs and capabilities of the reader. The picture brochure did not contain any form of information on complaints or service user comments. This continues to be listed as a recommendation. It is recommended that a review of the content of the information documents be completed to ensure that information is in the appropriate document. DS0000020076.V263608.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 The majority of assessed need were found to be recorded and planned however as at previous visits some deficits were found that had the potential to adversely affect the care received by service users. EVIDENCE: The care files of two service users were randomly selected and examined. It is accepted that most service users would not have the capacity to meaningfully participate in the care planning process. These contained risk assessments and recorded service users strengths and weaknesses. Where care plans were in place there were detailed approaches of how best to meet the service users needs. There was not a care plan in place that detailed when a medication which was to be taken on a periodic basis was due. Discussions with staff revealed it was regarded as the responsibility of the key worker to record this on the medication administration record however this was not recorded. This system could fail due to the potential absence of the staff member or absence of memory. It is an outstanding requirement from previous inspections that care plans must detail how all assessed needs are to be met. DS0000020076.V263608.R01.S.doc Version 5.0 Page 9 Some care reviews had taken place but these did not always meet the standard that they must be completed on a minimum 6 monthly basis. DS0000020076.V263608.R01.S.doc Version 5.0 Page 10 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): 16,17 Service users were offered many opportunities at Poplars to participate in activities of daily living both inside and outside of the home. EVIDENCE: Service users care files confirmed that daily routines and preferences were considered and recorded. Each service user had an allocated day dedicated to working alongside a staff member to participate in some household tasks such as tidying and cleaning their bedroom. There was also some service user participation in shopping for food for the home. Care files contained details of parental liaisons either by phone and letter and these appeared to be occurring on a regular basis. There was encouragement given to service users who were able to write to send letters to their families. Care detailed if the service user had capacity to hold the key to their bedroom. The kitchen at Poplars was domestic in style with some locked cupboards for cleaning materials. Menu’s were available on a 4 week rota. Records of the DS0000020076.V263608.R01.S.doc Version 5.0 Page 11 main meat/fish dish served with each meal were recorded along with the temperature recorded. Records did not indicate however the vegetables/accompaniments served or any desserts. It was therefore not possible to establish the overall nutritional balance of the meals. Where takeaways were purchased which was on a weekly basis there was no list of what was actually purchased. DS0000020076.V263608.R01.S.doc Version 5.0 Page 12 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): 20 Robust systems were not being implemented by staff to ensure that there was safe storage and administration of medications. EVIDENCE: The storage and administration of medications was examined. On one medication administration record correction fluid was used to obliterate a previous entry. Two medication spelling errors were found on medication administration records. It was of concern that one of these contained signatures to confirm this had been verified by two staff members and had not been identified. One medication administration record did not match the instruction on the pharmacy label regarding the time of administration. Staff spoken to said that this had been agreed with the GP but there were no records to support this. There were some differences evident in the way that over the counter complimentary/supplementary items were recording. One item was recorded on the medication administration records for one service user but another service user it was not recorded. This could potentially lead to double dosage if records of administration were not held. DS0000020076.V263608.R01.S.doc Version 5.0 Page 13 Some out of date items were found in the first aid box. A range of topical preparations without a date of opening was also found; staff discarded these during the inspection. The drug reference book available was dated September 2004. It is recommended that a drug reference source not older that 1 year is obtained. DS0000020076.V263608.R01.S.doc Version 5.0 Page 14 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): EVIDENCE: No standards in this section were formally assessed. Compliance regarding the previous requirement relating to the accurate recording of monies was checked. This confirmed balances were recorded accurately but not all transactions had double signatures to verify them, this is a good practice recommendation. Positively a pictorial complaints procedure was situated in a communal part of the home for service users to access. This was new since last inspection. DS0000020076.V263608.R01.S.doc Version 5.0 Page 15 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): EVIDENCE: No standards in this section were formally assessed. Compliance regarding the previous requirement that the garden required tidying was assessed. The garden had been tidied even though a liberal covering of autumnal leaves were evident. Staff said that during the summer service users had used and enjoyed the garden. It was observed that as at the previous inspection the dining furniture was an assortment of 3 styles of chair, some more suited to an office environment as opposed to promoting a homely environment. It is recommended that the purchase of new dining furniture is considered. DS0000020076.V263608.R01.S.doc Version 5.0 Page 16 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): 32,34,35,36 Work is required to ensure staff are fully supported through supervision and training to undertake the role for which they are employed. EVIDENCE: There were 6 care staff employed at the home, 4 of these hold at least an NVQ (National Vocational Qualification) level 2 in care meeting the 50 requirement. Further staff were enrolled on NVQ (National Vocational Qualification) courses. Staff personnel files were examined these contained all the required checks to ensure staff were suitably employed to work with vulnerable service users. A sample of staff supervision records were examined these indicated that regular supervisions were recorded up to May/June 2005 after this there appeared to be little recorded. Discussions were held and one staff member had begun to complete a schedule of staff supervisions. Staff training were examined. It was identified that staff were not receiving some basic elements of training and required updates. This included moving and handling and Basic Food Hygiene training. DS0000020076.V263608.R01.S.doc Version 5.0 Page 17 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): The home appeared to be well maintained with no obvious health and safety hazards however some supporting service records were not available to confirm this fully. EVIDENCE: The Manager was not duty at this visit and was spending some time away from the home to provide managerial support at a sister home in the organisation. A ‘floating’ manager had been deployed to Poplars during this period to provide managerial support. Tiers of management were in place to provide general support to staff at all times. Visits made on a monthly basis by a parent of a service user on behalf of the Provider had been completed. Some of the records of these were available at the home others were not. These were faxed through to Commission for Social Care Inspection but must be available at the home for the purpose of inspection. DS0000020076.V263608.R01.S.doc Version 5.0 Page 18 The fire log records were examined which indicated that the equipment and the system were checked at appropriate intervals. There was a designated staff member who did routine visual checks and staff training had been completed. Records relating to the 5 yearly periodic electrical test and landlords gas safety certificate could not be located at the home. These must be forwarded to the Commission for Social Care Inspection within 6 weeks. Portable appliance testing records were available and had been completed within the last year. Discussions regarding these records suggested they may be held at the organisations head office. A quality assurance review had been undertaken of all the organisations services with the results being published. This review process included input from a range of sources including parents. This document contained some abbreviations that many readers may not understand it is recommended that are written fully. DS0000020076.V263608.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 x x x x Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x x x x Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 x 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x DS0000020076.V263608.R01.S.doc Version 5.0 Page 20 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 15 Requirement Care must be taken to ensure that all aspects of assessed needs are covered in sufficient detail in care plans Previous timescales 30/03/05 7 30/07/05 Care plans must be reviewed on a minimum 6 monthly basis Records of foods served must be fully recorded Correction fluid must not be used to obliterate errors on any care records/official documents Medication administration records must be meaningfully checked and verified by two staff members to ensure they are accurate Topical preparations must have a recorded date of opening The medication administration record must reflect the administration instructions on the pharmacy label A system must be developed to ensure items in the first aid box are date checked and restocked as necessary Records of monthly visits made on behalf of the Provider in DS0000020076.V263608.R01.S.doc Timescale for action 31/12/05 2 3 4 5 YA6 YA17 YA20 YA20 15 Schedule 4 (13) 17 13 31/12/05 30/11/05 30/11/05 30/11/05 6 7 YA20 YA20 13 13 30/11/05 30/11/05 8 YA20 13 31/12/05 9 YA39 26 31/12/05 Version 5.0 Page 21 10 11 YA35 YA35 18 18 12 YA36 18 13 YA42 23 14 YA42 23 1accordance with Regulation 26 must be available at the home Staff must receive annual training updates in moving and handling Staff who have food handling responsibilities must receive Basic Food Hygiene and required updates A plan must be in place to ensure that staff receive recorded individual supervision at least six times annually The five yearly periodic electrical test certificate must be forwarded to the Commission for Social Care Inspection The Landlords gas safety certificate must be forwarded to the Commission for Social Care Inspection 31/01/06 31/01/06 31/12/05 31/12/05 31/12/05 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 5 6 Refer to Standard YA1 YA1 YA20 YA23 YA28 YA39 Good Practice Recommendations A review of the Statement of purpose and Service User Guide are required to ensure information is in the appropriate document The picture format Service User Guide and information pack should be developed to include residents views and information on how to make a complaint There should be a drug reference book in the home not dated above 1 year old All financial transactions undertaken on service users behalf should be verified by two signatories It is recommended that new dining room furniture is purchased Abbreviations should not be used in documents where potential readers may not understand them DS0000020076.V263608.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000020076.V263608.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!