Inspection on 08/09/05 for The Poplars

This inspection was carried out on 8th September 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Poplars 10/09/09

The Poplars 14/08/08

The Poplars 10/03/08

The Poplars 17/09/07

The Poplars 15/12/05

The Poplars 08/02/05

The Poplars 21/10/04

The Poplars 19/02/04

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

CARE HOME ADULTS 18-65 The Poplars Drayton Road Abingdon Oxfordshire OX14 5HY Lead Inspector Catherine Kane Announced 08 September 2005 10:00 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 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 Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Poplars H57-H08 S13126 The Poplars V238743 080905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Poplars Address Drayton Road, Abingdon, Oxfordshire, OX14 5HY Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01235 523630 01235 523630 haroon@caretech-uk.com Caretech Community Services Limited Mr Gordon Mackay Care Home 6 Category(ies) of Learning disability (6) registration, with number of places The Poplars H57-H08 S13126 The Poplars V238743 080905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: For one person over the age of 65 to continue to reside in the home. Date of last inspection 08 February 2005 Brief Description of the Service: The Poplars is a large detached house situated within easy reach of Abingdon town centre. The home is registered for up to six people with learning disabilities. The home has a spacious lounge, kitchen and dining room and a large garden with patio area. Each resident has their own bedroom. Each resident is supported to use local health care facilities. The home is run and managed by CareTech Community Services Ltd, a national organisation with experience in providing services for people with a learning disability. The Poplars H57-H08 S13126 The Poplars V238743 080905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection visit took place during the day of Thursday 8 September 2005. The purpose of the visit was to see how the home is meeting National Minimum Standards. The visit took almost six hours and the inspector spent this time with all six residents who currently live in the home, the registered manager and staff on duty. The inspector listened to their views and discussed their experiences. The inspector also read notes kept in the home, saw how staff help residents look after and take their medication and was present during the midday meal. The inspector also looked at staff files and spoke with a member of staff from CareTech human resources. The home had a friendly atmosphere. Residents told the inspector about the things that are important for them and how they like their home to be run. The six residents were relaxed in the company of the staff on duty. The registered manager, who has worked in the home for some time, was very popular with the residents. One resident liked their bedroom but wants to move to a home with no stairs. A requirement relating to recruitment records that must be kept in the home has been made at the previous two inspections. This has not been met. If this requirement is not met by the further revised timescale then CSCI may have to consider taking enforcement action. The inspector would like to thank each resident for making her feel very welcome and thank the registered manager and his staff team for their assistance during the inspection. What the service does well: What has improved since the last inspection? Progress has been made in supporting one resident with their wish to find a new home. Staff awareness of adult protection procedures has improved. The Poplars H57-H08 S13126 The Poplars V238743 080905 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Poplars H57-H08 S13126 The Poplars V238743 080905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Poplars H57-H08 S13126 The Poplars V238743 080905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None The inspector has not made a judgement on these standards on this visit. The outcomes of these standards will be looked at during the next inspection. EVIDENCE: The Poplars H57-H08 S13126 The Poplars V238743 080905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 Since the last inspection progress has been made in supporting one resident with their wish to find a new home. EVIDENCE: The inspector spent time listening to one resident who told her that they wanted to move to a new home where there were no stairs, or to be near people they like. The resident was able to tell the inspector about how the manager and staff were helping them with this and what was happening. The inspector encourages the registered manager and his staff team to continue with their support to this resident to achieve this. The Poplars H57-H08 S13126 The Poplars V238743 080905 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 16 and 17 Residents have limited opportunities to take part in activities of their choice and within their local community. Some residents’ privacy in their bedroom and freedom to move around the home is potentially compromised by the unsuitable locks fitted on some residents’ bedroom doors. Some residents take responsibility to make sure they keep their home clean and tidy. Some residents help with the planning of meals and are very happy with the meals provided. EVIDENCE: The inspector saw how the staff on duty had built a strong bond with each resident as they shared jokes together. The Poplars H57-H08 S13126 The Poplars V238743 080905 Stage 4.doc Version 1.40 Page 11 During the inspection the inspector spent some time getting to know residents who told her about the things that are important to them and what things they like to do. During the inspection the inspector observed that three residents preferred to stay in their rooms for most of the day. One other resident said, “I like to go to the shops”. Another wanted to go to the pub. From talking with residents, staff and the registered manager, the inspector understood that it was very important for each person to be able to get out and about every day. Notes kept in the home indicated that some staff time was allocated to taking residents out. This was not always as much as some residents would like and does not happen for each resident every day. The registered manager said that there are no other authorised drivers in the current staff team so this limits opportunities on where residents can go. One resident was obviously delighted when the registered manager took him for a drive to the local pub after lunch on the day of the inspection. A recommendation was made at the previous inspection to improve the standard of activity recording so that the activity provision for each resident can be properly monitored. This had not been done in sufficient detail for the inspector to see if the situation had improved. The registered manager must consult with each resident about their personal interests and he must make arrangements that each resident is provided with opportunities to take part in interesting and fulfilling social and leisure activities, in the home and in their local community, taking into account their needs and wishes. The inspector saw how residents took responsibility for making sure their home is clean and tidy by sharing some housework tasks and helping staff. A recommendation was made at the previous inspection to do something about the unsuitable locks on residents’ bedroom doors. These locks are of a type that could not be unlocked in an emergency if a key was in the lock on the inside. One bedroom door was fitted with a star lock with a key hanging on a hook outside the door where there was the potential risk for a resident to be locked in the bedroom, either accidentally or intentionally. From what the inspector saw and discussion with the registered manager this issue had not been fully addressed. The registered manager must consult with each resident and where the resident is not able, or does not wish to use a lock on their bedroom door, this must be clearly recorded through using the care planning process. Where locks are fitted these must be of a type that can be openable from outside in an emergency and cannot be locked from the outside so as to prevent a resident leaving their room if they wish. The inspector was invited by residents to join them for a very nice cooked lunch on the day of the inspection that one resident helped to prepare. Each resident could choose where they preferred to eat and they told the inspector about the meals they liked. The Poplars H57-H08 S13126 The Poplars V238743 080905 Stage 4.doc Version 1.40 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 standard(s) 20 Recording systems for the administration of residents’ medication could be improved. EVIDENCE: Two confident staff members showed the inspector how residents were supported to look after and take their medication. The system was generally good. The inspector strongly recommends that the home follows guidance issued by the Royal Pharmaceutical Society of Great Britain. The inspector recommends that any handwritten entries to the medication administration record (MAR) sheets are signed by another member of staff assessed as competent in accordance with good practice. The inspector also recommends that written records of staff assessments of competence and sample of those staff’s initials be kept in the home and available for inspection. The Poplars H57-H08 S13126 The Poplars V238743 080905 Stage 4.doc Version 1.40 Page 13 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 standard(s) 23 Staff awareness of adult protection procedures has improved. EVIDENCE: Staff who met and spoke with the inspector during this inspection were able to provide a clear understanding of local adult protection procedures in line with the Oxfordshire Multi-agency Codes of Practice. The Poplars H57-H08 S13126 The Poplars V238743 080905 Stage 4.doc Version 1.40 Page 14 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 standard(s) 24, 26, 28 and 30 The standard of décor throughout the home, except the kitchen, is generally good and is a homely and comfortable environment. EVIDENCE: The home has a large modern kitchen and was seen on the day of the inspection to be the heart of the home. This seemed to be the most used room in the home where residents and staff spent a lot of their time together sharing news, chatting, having cups of tea and preparing meals. Kitchen cupboards needed repairs and worktops were scratched and worn. The environmental health officer’s visit in April 2004 refers to a proposed kitchen update, this is now well overdue. One resident told the inspector “this kitchen is not very nice”. The registered manager must provide the inspector with details with timescales for the update of the kitchen. Residents’ bedrooms seen by the inspector were spacious and clearly furnished and decorated in the occupant’s choice of style. Residents who invited the inspector to see their bedroom were obviously proud of how they kept their room tidy and liked to spend time there. The Poplars H57-H08 S13126 The Poplars V238743 080905 Stage 4.doc Version 1.40 Page 15 The carpet in one resident’s bedroom was tatty and stained. The registered manager must provide the inspector with details with timescales for the replacement to a more suitable flooring in this resident’s bedroom within the planned maintenance and renewal programme for the home. On the day of the inspection the home was seen to be clean and tidy. The Poplars H57-H08 S13126 The Poplars V238743 080905 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 34 and 35 Staff spoke favourably of working in this home. A review of the staffing structure would benefit residents and provide them with greater opportunities. The information required about staff that must be kept in the home must improve further. The training programme undertaken by staff is limited. EVIDENCE: The inspector spoke with several members of the staff team on the day of the inspection and viewed minutes kept of team meetings. From information provided it seemed that the home has managed to recruit to vacant positions, thus using less agency staff. One staff member was not familiar with the General Social Care Code of Practice. This was seen to be available in the home’s office. The current staffing arrangement has been in place for many years. The registered manager related that since this was set, changes to the level of residents’ planned activities away from the home during the day has The Poplars H57-H08 S13126 The Poplars V238743 080905 Stage 4.doc Version 1.40 Page 17 decreased. This means that most residents stay at home most of the time and are likely to get bored. The inspector strongly recommends that the registered manager reviews the staffing arrangements based on Department of Health guidance and relating to the needs of residents. The inspector viewed staff records chosen at random for 3 members of staff during this inspection. There were still shortfalls in the information that was available that is required by legislation and must be kept in the home. The inspector spoke by telephone with a representative of CareTech human resources department situated at their head office. Requirements relating to regulations regarding the employment of staff have been made at previous inspections. The registered manager must ensure that all aspects of the regulations regarding the employment of staff are met. This includes all information and documents in respect of staff who work in this home required by regulation are kept in the home and available for inspection. From information provided by staff about the limited training opportunities the inspector doubts this home will achieve the expected target of 50 NVQ qualified staff by the end of 2005. The Poplars H57-H08 S13126 The Poplars V238743 080905 Stage 4.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 This organisation places importance on consulting residents and their representatives about the services it provides. The systems to maintain health, safety and welfare of residents and staff are generally good. EVIDENCE: The inspector has been invited to local meetings where residents’ relatives or representatives have opportunities to consult the registered manager and other senior CareTech managers. The inspector receives copies of the proprietor’s representative’s monthly visit reports. Health, safety and welfare records kept in the home were made available for inspection. The registered manager must ensure that staff fire safety training is carried out and the fire safety training log is maintained. The Poplars H57-H08 S13126 The Poplars V238743 080905 Stage 4.doc Version 1.40 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 x x x x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 x 2 x 3 Standard No 11 12 13 14 15 16 17 x 2 2 x x 2 3 Standard No 31 32 33 34 35 36 Score 3 x 2 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Poplars Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x H57-H08 S13126 The Poplars V238743 080905 Stage 4.doc Version 1.40 Page 20 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 13 Regulation 16(2m&n) Requirement Timescale for action 30/11/05 2. 16 17(1a) Sch 3(3q) 3. 24 16(2g) The registered manager must consult with each resident about their personal interests and he must make arrangements that each resident is provided with opportunities to take part in interesting and fulfilling social and leisure activities, in the home and in their local community, taking into account their needs and wishes. The standard of activity recording must be improved so that the activity provision for each resident can be properly monitored. The registered manager must 30/11/05 consult with each resident and where the resident is not able, or does not wish to use a lock on their bedroom door, this must be clearly recorded through using the care planning process. Where locks are fitted these must be of a type that can be openable from outside in an emergency and cannot be locked from the outside so as to prevent a resident leaving their room if they wish. The registered manager must 30/11/05 Version 1.40 The Poplars H57-H08 S13126 The Poplars V238743 080905 Stage 4.doc Page 21 4. 34 19(1b) 5. 42 23(4d&e) provide the inspector with details with timescales for the update of the kitchen and the flooring in one residents bedroom within the planned maintenance and renewal programme for the home. The registered manager must 31/01/06 ensure that all aspects of the regulations regarding the employment of staff are met. This includes all information and documents in respect of staff who work in this home required by regulation are kept in the home and available for inspection. The registered manager must 31/01/06 ensure that staff fire safety training is carried out and the fire safety training log is maintained. 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. Refer to Standard 20 Good Practice Recommendations The inspector strongly recommends that the home follows guidance issued by the Royal Pharmaceutical Society of Great Britain. The inspector recommends that any handwritten entries to the MAR sheets are signed by another member of staff assessed as competent in accordance with good practice. The inspector also recommends that written records of staff assessments of competence and sample of those staff’s initials be kept in the home and are available for inspection. The inspector strongly recommends that the registered manager reviews the staffing arrangements based on Department of Health guidance and relating to the needs of residents. 2. 33 The Poplars H57-H08 S13126 The Poplars V238743 080905 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Burgner House, 4630 Kingsgate, Cascade Way, Oxford Business Park South, Cowley, Oxford OX4 2SU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Poplars H57-H08 S13126 The Poplars V238743 080905 Stage 4.doc Version 1.40 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. 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