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Inspection on 10/01/06 for The Poplars Nursing Home

Also see our care home review for The Poplars Nursing Home for more information

This inspection was carried out on 10th January 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents confirmed that their family and friends were always made very welcome at the home. A visitor also confirmed this to the inspector. Some of the residents were very willing to speak to the inspector, and at this visit several residents were engaged in conversation. A discussion took place with two ladies who were sitting in the downstairs dining room. Both residents were full of praise for the home, the care that they receive, and the attitude and kindness of the staff. It was also determined that they considered that staff show them great respect and that they always listened and responded to their daily needs.

What has improved since the last inspection?

Some bedrooms have been decorated and fitted with new carpets.

CARE HOMES FOR OLDER PEOPLE The Poplars Nursing Home Rolleston Road Burton On Trent DE13 1JT Lead Inspector Mrs Sue Mullin and additional inspector Mrs Yvonne Unannounced Inspection 10th January 2006 10:30 X10015.doc Version 1.40 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 The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 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 Older People. 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. The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Poplars Nursing Home Address Rolleston Road Burton On Trent DE13 1JT 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) 01283 562842 01283 564642 Tawnylodge Limited Mrs Deborah Jane Watson Care Home 60 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (25), of places Physical disability (60), Physical disability over 65 years of age (60) The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD Minimum age 60 years Date of last inspection 2nd August 2005 Brief Description of the Service: The home is comprised of an extended two-storey building situated near to the town of Burton on Trent. The establishment provides personal and nursing care for elderly people with a bed capacity of 60. The home may also admit up to 5 people suffering with Dementia. There are forty-eight single and six shared bedrooms; however, currently two of the double rooms are occupied on a single basis. Nineteen rooms have en suite facilities. The home has spacious accommodation, including 4 lounges on the ground floor and a further two upstairs. There is a bus service nearby and shops are nearby. The grounds and gardens are well maintained and provide easy access for wheelchairs. The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors undertook this unannounced inspection on 10th January 2006. The total time spent for the inspection, including pre and fieldwork amounted to 12.5 hours. A tour of the premises took place and some Health and Safety records were inspected. Care plans were examined and residents and relatives were asked to comment on the care provided within the establishment. Generally those asked were complimentary about the standards of hands on care. Staff practice and behaviours were observed throughout the inspection and interaction between all parties was courteous, respectful and friendly. It was disappointing to note that some of the requirements made at the last inspection had not been met. 12 requirements have been made following this inspection and not all the National Minimum Standards were inspected on this occasion. Further follow up visits will be undertaken until the home satisfactorily meets all requirements made. Training, supervision, induction and recruitment will all be reviewed thoroughly on the next inspection. What the service does well: Residents confirmed that their family and friends were always made very welcome at the home. A visitor also confirmed this to the inspector. Some of the residents were very willing to speak to the inspector, and at this visit several residents were engaged in conversation. A discussion took place with two ladies who were sitting in the downstairs dining room. Both residents were full of praise for the home, the care that they receive, and the attitude and kindness of the staff. It was also determined that they considered that staff show them great respect and that they always listened and responded to their daily needs. The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The catering aspects in the home are not suitable or appropriate and must be urgently reviewed. A new menu plan must be implemented which meets the needs of all of the elderly residents. Fresh vegetables must be on offer along with a suitable choice of hot food at the main meal of the day. One resident and her daughter were engaged in conversation and the resident stated that her new years dinner ‘was very disappointing’. She went on to say that there was ‘not one single piece of fresh veg and although she could smell the stuffing, none was on her plate’. The resident wished there was more choice of ‘ proper meals’ in the home. Milk must not be diluted and sufficient stocks and supplies of good quality food must be available. Food and drink must be served hot to all residents in the home particularly those on the top floor. This will be checked on the next inspection. The registered person must ensure that these issues are rectified in line with Environmental Health regulations: • • • • • • The Bain-marie was broken in that the hot plate did not warm up The dishwasher did not work properly and did not sufficiently clean the crockery The fly screen on the window was torn There were no foot operated bins in use in the kitchen The cleaning schedule is not completed Fridge and freezer temperatures had not been recorded for some time The registered individual must supply the home with an effective care planning system that enables care staff to document all residents’ requirements in line with Schedule 3. The monitoring of the weights of residents also needs to be improved as, although these were recorded in the weight book they were not always transferred to the care plan and a nutritional assessment had not always been carried out in relation to this. Loss of weight was identified in relation to 6 residents on the nursing unit but not all of these residents had a plan of care in relation to nutrition, in fact not all weight losses had been identified in the care plan. The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 7 Bed rail risk assessments must be in place where used and reviewed regularly. Maintenance of bed rails must be undertaken and recorded. Where possible relatives should be encouraged to acknowledge that bedrails are in use, in writing. All staff must receive adequate fire drills in line with fire authority requirements. (Fire safety training had taken place.) The home must remove two glass windowpanes leaning up against wall in ground floor dining room. These constitute a real hazard to resident’s safety. The care manager should improve communication throughout all disciplines of the home by holding regular staff meetings. These should be documented and available for inspection when required. The registered care manager must provide details of the cause of death on regulation 37 notices. The registered person must provide more activity hours so that individual assessment of social and therapeutic needs and abilities are met. The registered individual must supply monthly regulation 26 notices to the CSCI. Rooms were generally decorated when empty but there was no projected ongoing redecoration programme for the home. A recommendation was made in this regard. 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 Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 Although a pre admission assessment was undertaken, not all residents could expect to have their identified needs met. EVIDENCE: Several care plans were seen and although they contained a pre admission assessment, it was clearly evident in some instances that identified problems had not been implemented properly or followed up. The care plans were based on the Activities of Daily Living and a pre-admission assessment of needs. This initial assessment was quite thorough but then identified needs were not always followed up by the development of a specific care plan, hence the plans were not very comprehensive. The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 10 The involvement of healthcare professionals was evident, including visits by the GP, dentist, chiropodist, optician and visits to the hospital and outpatients as required. Nursing intervention was documented but it was identified that this was not always followed through. An example of this was a resident who was admitted to the home with a pressure sore and a care plan had been developed but then no further documentation was in place to identify what had happened to this sore and what further treatment, if any had taken place. All identified areas of care must be documented carefully, by appropriately trained staff. A care plan examined contained paperwork, assessments and information that were no longer applicable to the care now being delivered. It is imperative that the system of care plans used is reviewed and changed to a more effective system. This was discussed with the manager during feedback and an immediate requirement to address this was issued. The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 There is no clear or consistent care planning system in place to adequately provide staff with the foundation to assess, plan, implement or evaluate care needs. The home could not demonstrate that they satisfactorily meet the care needs of the residents. Medication was administered in a safe manner and residents could expect to have their privacy and dignity upheld. EVIDENCE: A selection of care plans were examined on the nursing unit. It was quickly identified that these had not improved since the previous inspection. The care plans were evaluated monthly but this evaluation was documented in the daily report and usually summed up with one paragraph. The identified problems and needs were not evaluated individually. The first care plan examined was that of a resident admitted in November. The named nurse was not documented and there was no risk assessment in place for the risk of falls, despite this resident having had a history of these. The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 12 There was evidence of participation by the resident’s representative and there were signatures in agreement with the care plan. The second care plan contained incorrect information, in that the named nurse and key worker were wrongly identified as being responsible for care planning. The weight chart was blank, although the resident had been weighed and this had been recorded in the weight book, it had not been transferred to the main body of the care plan. It was concerning to note that this resident, along with others who used bedrails, had no risk assessment in place for the use of these and no evidence that these rails were checked on a regular basis or that the resident/representative had been consulted on their use. Without this information in place the use of bedrails could be misconstrued as a method of restraint. The monitoring of the weights of residents also needs to be improved as, although these were recorded in the weight book they were not always transferred to the care plan and a nutritional assessment had not always been carried out in relation to this. Loss of weight was identified in relation to 6 residents on the nursing unit but not all of these residents had a plan of care in relation to nutrition, in fact not all weight losses had been identified in the care plan. The medication process was examined with the nurse in charge. Medication is now administered to residents receiving personal care by the care staff who have undergone training in this area. The training has been given by Boots Pharmacist and backed up by the home’s own medication training. The care assistant was observed administering medication on the ground floor and was questioned on the process by the inspector. The Medication Administration Record Charts were also examined. These were found to be in order and the care assistant was observed to be proficient in her role. The same was applied to the nurse and found to be in order. The receipt, storage, administration and disposal of controlled medication was examined and found to be in order. Privacy and dignity was afforded to residents and staff were observed as being polite and respectful toward them. Discussions with residents confirmed that they felt that their dignity was upheld and that staff were respectful with them. The inspector spoke with a care assistant who had worked at the home for many years. She explained the importance of maintaining dignity and privacy for the residents. The inspector spoke with a resident whom she had met with at the previous inspection and found that she continued to be happy with the care provided at the home. She was spending time in her room – which had been personalised to her own taste with her china doll collection and her two caged birds for company. The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 13 The registered individual must supply the home with an effective care planning system that enables care staff to document all residents’ requirements in line with Schedule 3. A requirement has also been made to ensure that care staff must monitor resident’s weights and linking this in with the nutritional care plan. A requirement has also been made so that any nursing intervention identified must be followed through in the care plan to show regular evaluation and progress. Bed rail risk assessments must be in place where used and reviewed regularly. Maintenance of bed rails must be undertaken and recorded. Relatives where possible must acknowledge bedrails in place in writing. The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 The delivery of therapeutic activities at the home was inadequate and not geared to meeting individual needs. Residents could not expect a good choice of food at the main meal of the day. EVIDENCE: The home no longer employed an activities co-ordinator and this had had an overall effect on the provision of therapeutic activities at the home. The programme of activities and entertainment was in need of improvement with little in the way of organisation or planning. Residents had not been individually assessed as to their preferences and abilities in relation to therapeutic activities. There had been entertainment provided over the Christmas period and residents spoken to confirmed that this had been enjoyable. There was an open visiting policy at the home and visitors were able to visit at any reasonable time. The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 15 When asked about links with the community, a care assistant stated that this was limited mainly to families taking residents out, Church Services being held at the home and trips out with the residents in the Summer months. The registered person must provide more activity hours so that individual assessment of social and therapeutic needs and abilities are met. The catering aspects in the home need to be urgently reviewed. A new menu plan must be implemented which meets the needs of the elderly residents in your care. There was some evidence of choices being made in relation to the meals, albeit choice was limited. Menus provided at inspection were not being followed. There was no fresh vegetables served in the home all produce used was frozen with the exception of mashed potatoes which were served every day. There was limited choice of fresh fruits available, which depended on what the maintenance man would purchase from the supermarket. The home is registered for 60 persons and fresh produce should be delivered regularly to the home in line with HACCP requirements and not be dependant on what can be fetched by staff within the home. Menus should be followed and stocks and supplies delivered to the home in time to ensure all dietary requirements in the home are met. One resident and her daughter were engaged in conversation and the resident stated that her new years dinner ‘was very disappointing’. She went on to say that there was ‘not one single piece of fresh veg and although she could smell the stuffing none was on her plate’. The resident wished there was more choice of ‘ proper meals’ in the home. Fresh vegetables must be on offer along with a suitable choice at the main meal of the day. Milk must not be diluted and sufficient stocks and supplies of good quality food must be available. Food and drink must be served hot to all residents in the home particularly those on the top floor. Catering staff spoken to informed the inspector that: • • The Bain-marie was broken in that the hot plate did not warm up The dishwasher did not work properly and did not sufficiently clean the crockery The inspector noted that: • The fly screen on the window was torn • There were no foot operated bins in use in the kitchen • The cleaning schedule is not completed • Fridge and freezer temperatures had not been recorded for some time Requirements have been made in respect of these issues. The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 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. The arrangements for dealing with complaints were positive and constructive. Service users and their relatives/friends knew that if they wished to complain, staff would listen and make every attempt to resolve the complaint to their satisfaction if at all possible. EVIDENCE: Copies of the complaints procedure were on display in the home, and included information on how to complain directly to the CSCI. Residents and a relative spoken to confirmed that they felt able to air their views and express their concerns to staff at any time. No complaints have been received by CSCI since the last inspection. The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23,26 There were no programmes in place to ensure that upgrades and improvements in all resident areas of the home are ongoing. Not all areas of the home that residents have access to were safe. The home was clean and hygienic. EVIDENCE: The environment on the first floor was quite well presented. The corridor areas were bright and attractively decorated. Bedrooms had been personalised and adapted to meet individual needs with evidence of residents having brought in personal possessions from home. The environment was clean with no mal odours noted and there was the provision of hand washing facilities, protective gloves, aprons and clinical waste in allocated areas. The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 18 There was a bedpan washer in the sluice, which was in operation at the time of the inspection. The domestic assistant was cleaning and vacuuming at the time of the inspection. There was evidence of aids and adaptations in place to help with mobility, moving and handling and maintaining independence. There was also evidence of the use of pressure relieving equipment including specialist mattresses and cushions. However there were two very large glass windowpanes leaning up against wall in ground floor dining room. Two residents were sitting next to these panes of glass and one resident who could mobilise gentle was assessed as having a risk of falls. These constitute a real hazard to resident’s safety and must be removed all areas in use by residents must be safe. The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28. Residents could expect continuity of care provided by sufficient levels of motivated staff. Discussion with management/staff and residents and a relative all felt confident that residents are in safe hands. EVIDENCE: As the home has been registered under South Staffs Health Authority prior to 31st March 2002, the levels and skill mix implemented at that time must be maintained. On the day of the inspection the home had 21 residents receiving general nursing care and 23 receiving general residential care. On the day of the inspection the home were appropriately staffed. The care manager Mrs Watson is fully supernumerary. The home also has a deputy manager who works 4 days a week. There is one qualified nurse on duty during the twenty-four hour period. Additionally there are 9 care staff on the early shift and 7 on the late shift and 4 care staff over the night shift. The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 20 All shifts are full shifts and agency staff are deployed were regular staff cannot cover. There are sufficient laundry and domestic staff over a seven-day period. However, it would be beneficial to have evening domestic cover. There is a cook and a catering assistant in the kitchen daily. There is an administrator for the home who works up to 25 hours. There is also a handyman (40 hours per week) and a painter and decorator (20 hours per week.) The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,38 There were no recognisable robust quality assurance systems in place in the home and the home was not run entirely in the best interests of the residents. EVIDENCE: Several members of staff were asked if they had attended staff meetings in the home recently, all those spoken to confirmed that they had not attended a staff meeting for ‘ a long time’. Neither the maintenance man or care manager knew of the problems in the kitchen, with regard to equipment not working and broken fly screens. The care manager should improve communication throughout all disciplines of the home by holding regular staff meetings. These should be documented and available for inspection when required. The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 22 The registered individual must supply monthly regulation 26 notices to the CSCI. Following discussions with the handyman and the painter it was established that hot water temperatures were monitored and recorded. Fire tests were undertaken weekly, emergency lighting tested monthly and all reordered in line with requirements. The two hoists were serviced twice yearly and the portable appliance testing was undertaken in November 2005. Rooms were generally decorated when empty but there was no projected ongoing redecoration programme for the home. A recommendation was made in this regard. Bed rail risk assessments were not in place. These must be undertaken where used and reviewed regularly. Maintenance of bed rails must be undertaken and recorded. The registered care manager must provide details of the cause of death on regulation 37 notices. The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 1 X X X 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X X X X 2 The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 13(4)(a) Requirement Remove two glass windowpanes leaning up against wall in ground floor dining room. These constitute a hazard to resident’s safety. The registered individual must supply the home with an effective care planning system that enables care staff to document all residents’ requirements in line with Schedule 3. Bed rail risk assessments must be in place where used and reviewed regularly. Maintenance of bed rails must be undertaken and recorded. • Robust monitoring of residents weights and linking this in with the nutritional care plan. • Any nursing intervention identified must be followed through in the care plan to show progress and regular evaluation. The home must only admit residents whose identified needs can be fully met, once resident DS0000022360.V277040.R01.S.doc Timescale for action 10/01/06 2 OP7 17(1a) 15(1)2) (b,c) 10/03/06 3 OP38 13(4c) 15(1)2) (b,c) 15(1)(2) (b)(c) 01/02/06 4 OP8 10/01/06 5 OP4 15(1) 10/01/06 The Poplars Nursing Home Version 5.1 Page 25 6 OP15 16 (2)(i) 7 8 9 OP38 OP33 OP31 23 (4)(e) 26 (2)(a) (3)(4)(5) 21 (2) 10 OP12 16(2)(n) 11 OP31 37(1)(a) 12 OP15 16(2)(g) in the home. The catering aspects in the home need to be reviewed. A new menu plan must be implemented which meets the needs of all the residents. Fresh vegetables must be on offer along with a suitable choice of hot food at the main meal of the day. Milk must not be diluted and sufficient stocks and supplies of good quality food must be available. Food and drink must be served hot to all residents in the home particularly those on the top floor. All staff must receive adequate fire drills in line with fire authority requirements. The registered individual must supply monthly regulation 26 notices to the CSCI. The care manager should improve communication throughout all disciplines of the home by holding regular staff meetings. These should be documented and available for inspection when required. The registered person must provide more activity hours so that individual assessment of social and therapeutic needs and abilities are met. The registered care manager must provide details of the cause of death on regulation 37 notices. The registered person must ensure that these issues are rectified in line with Environmental Health regulations: • The Bain-marie was broken in that the hot plate did not warm up • The dishwasher did not work properly and did not DS0000022360.V277040.R01.S.doc 10/01/06 01/02/06 10/02/06 10/02/06 01/03/06 10/01/06 10/02/06 The Poplars Nursing Home Version 5.1 Page 26 • • • • sufficiently clean the crockery The fly screen on the window was torn There were no foot operated bins in use in the kitchen The cleaning schedule is not completed Fridge and freezer temperatures had not been recorded for some time 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 OP19 Good Practice Recommendations Rooms were generally decorated when empty but there was no projected ongoing redecoration programme for the home. It would beneficial to formulate a workable refurbishment programme. It would be beneficial to have evening domestic cover. 2 OP26 The Poplars Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Nursing Home DS0000022360.V277040.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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