Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 02/08/05 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 2nd August 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.

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

There was good interaction between staff and residents, and those residents asked (who were able to comment) were very happy with their stay in the home. These aspects were established following discussions with residents, visitors, and staff and by direct observation of both inspectors.

What has improved since the last inspection?

No complaints, incidents or reports of abuse had been received since the last inspection. However, there have been no significant improvements in this care service since the last inspection.

CARE HOMES FOR OLDER PEOPLE The Poplars Nursing Home Rolleston Road Burton on Trent DE13 1JT Lead Inspector Susan Mullin Unannounced 2 August 2005 11:00 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 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 E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 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 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 5 DE(E) registration, with number 25 OP of places 60 PD 60 PD(E) The Poplars Nursing Home E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: PD Minimum age 60 years Date of last inspection 09 March 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 several of the double rooms are occupied on a single basis. Nineteen rooms have en suite facilities.The home has 4 lounges on the ground floor and a further two upstairs.There is a local bus service and shops are nearby. The grounds are well maintained and provide easy access for wheelchairs.However, garden area is minimal. There is a large car parking area. The Poplars Nursing Home E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspection officers made this statutory unannounced visit on The 2nd August 2005. The inspection was undertaken using the National Minimum Standards for Older People as a reference. The total time spent for the inspection, including preparation amounted to 9.5 hrs. The inspection included the following elements; a tour of the building, inspection of records relating to provision of care, discussions with several residents and relatives and also staff members, observation and sampling of other services provided such as catering and laundry, an inspection of the managerial aspects such as staffing, quality assurance and health & safety. The registered care manager, who is a first level nurse, was in charge of the home accompanied by two more registered nurses and nine care assistants. Ancillary staff on duty included; 1 cook and 1 catering assistant, 2 domestic staff, 1 laundry worker, 1 maintenance/ gardener, and a business support worker. These staffing levels were adequate to meet the needs of current 50 residents in the home. The total of 50 residents included; 21 receiving nursing care and 29 people receiving personal care for needs associate with old age and physical disability. However, it was some time after the start of the inspection that staff were able to ascertain the exact amount of residents in the home and those that required nursing care. This concern is discussed further in the report. Domestic and laundry services were adequately provided. The home provided adequate areas for residents, including communal and dining areas. Bathing/toilet facilities were adequate, clean and warm. Catering services and facilities fell well below acceptable national minimum standards. 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 very 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. Residents should not be dependant on what can be fetched by staff within the home, on an ad-hoc basis. Menus should be followed and stocks and supplies delivered to the home in time to ensure all dietary requirements, as stated in the statement of purpose are met. The Poplars Nursing Home E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 Page 6 Privacy, dignity and choice aspects for residents were being upheld. However, health, personal and social care needs had not all been met or fully documented. Some health and safety aspects had not been given a high priority and shortfalls identified in the body of the report must be addressed. Recruitment aspects still showed some anomalies and all staff must provide two written references prior to being employed in the home. Financial aspects were correctly addressed and recorded with safeguards to residents. Mandatory staff training was ongoing with induction training in place. The care manager stated that care staff had received some formal supervision sessions. The Commission are still not receiving monthly regulation 26 notices and this must now be addressed. 19 requirements and 2 recommendations, against the regulations and the minimum standards, have been made as a result of this inspection. These are outlined at the end of the report. It was very disappointing to note some many shortfalls in relation to the National Minimum Standards and you will continue to be inspected unannounced by this Commission, until all standards are satisfactorily met. What the service does well: What has improved since the last inspection? What they could do better: General management aspects were fair, with some degree of quality assurance taking place. However, quality assurance aspects were still not comprehensive enough to meet the national minimum standards. This was discussed at length and further procedures must be put into place in the very near future. Name Version 1.10 Page 7 New menus must be formulated and agreed by the Commission. These should then be followed religiously and stocks and supplies delivered to the home to ensure all dietary requirements in the home are met. This will be thoroughly checked on the next unannounced inspection. Adequate assessment and subsequent care planning must be further improved to ensure that the Home is able to meet the needs of the residents, both new and established. A number of areas of need have been identified during inspections, which when checked against the care plans, are not recorded. A selection of care plans were examined at the time of the inspection and the care of the residents was tracked. It was identified that care plans had not been developed adequately. There was no adequate risk assessment in place pertaining to individual use of bedrails. Observation of residents in bed using bedrails, identified that there were some with gaps between the mattress and the bedrail, which needed risk assessing. One resident had a bedrail in use with no bumper and was very agitated in bed. The chances of entrapment with this lady were increased because of her agitation. Again, a risk assessment is required. Activities are being organised for the residents, but following discussions it was evident that there are some of their preferences for daily life are not being considered. At present the activity hours are limited to 21 hours per week. This should be increased to meet the needs of the whole residential occupancy. The recruitment procedures in the Home do not fully protect the residents and the appropriate checks and records kept, must be made before staff are employed. A tour of the environment was undertaken and whilst the Home has the potential to offer comfortable surroundings for the residents, there are some areas, which require further work to meet the standards. Responsibilities under health and safety are a high priority and must be addressed as soon as possible. Doors must not be wedged open other than with a fire authority approved mechanisms. Further health and safety training is required to all disciplines of staff in the very near future. The registered care manager must take into account residents and relatives views into consideration, at regular intervals. These results should be documented and avaialble at inspection when required. 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 E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Poplars Nursing Home E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 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 standard(s) 1,2,4 Information had been available for prospective service users, and they had been enabled to make an informed choice about residing in the home. Individual health, personal and social cares needs had been established prior to admission but were not all fully met once a resident in the home. This could have a negative effect on the quality of care delivered to meet needs. EVIDENCE: A service user guide was seen in use, along with the statement of purpose. Contracts had been agreed and signed by residents/representatives. The documentation seen, and a discussion with residents/representatives, evidenced that residents had been assessed, prior to admission and they had been enabled to make a choice about the home. The community care plans provided by the social worker, as part of the individual needs assessment process, were seen within the service user plans. The Poplars Nursing Home E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 Page 10 However, examination of the care planning system did not confirm that all residents and relatives had been fully involved and in agreement with the ongoing assessments. There was little evidence to support residents were receiving all care as identified prior to admission. The home must ensure that the care staff employed have the skills and experience to deliver the services and care, that the home offers to provide. This was discussed at the feedback of the inspection and the care manager will now address these concerns. The Poplars Nursing Home E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 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 standard(s) 7,8,9,10 There was no clear or consistent care planning system in place to provide staff with the information they need to satisfactorily meet residents’ needs. The policies and procedures in relation to the medication process were adhered to as required. EVIDENCE: A selection of care plans were examined at the time of the inspection and the care of the residents was tracked. It was identified that care plans had not been developed adequately. In relation to a resident who had been admitted on 5/5/05, there was no working care plan in place. There was an initial assessment, which identified some problems/needs, but care plans had not been developed in respect of these. No risk assessments were in place and the Waterlow risk and handling assessment had not been completed and were left blank. The Poplars Nursing Home E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 Page 12 For another resident, evaluations had not been documented in the care plan but were written on the daily report. This is unacceptable as it renders the care plan unworkable. Weights were not recorded in the care plan. They had been undertaken and results written in the weight book but these had not been transferred. There was no adequate risk assessment in place pertaining to individual use of bedrails. Observation of residents in bed using bedrails, identified that there were some with gaps between the mattress and the bedrail, which needed risk assessing. One resident had a bedrail in use with no bumper and was very agitated in bed. The chances of entrapment with this lady were increased because of her agitation. Again, a risk assessment is required. Through case tracking it was discovered that care was not always delivered as per care plan. Although individual care plans on the second floor unit were more comprehensive then those on the ground floor unit, the care outlined in the plans was not always followed. One lady was sitting in her room with no access to fluids although her care plan stated that, due to her being catheterised, she needed more fluids than is normally required. This lady, who was immobile, was left sitting in her room with the call bell out of her reach and the bedroom door closed. When asked how she would call for assistance she stated that she would have to wait until someone came in to her. Her care plan stated that the call bell should be left within her reach at all times. The care plans for the residents accommodated on the second floor had been evaluated on a monthly basis. However, for those records seen, evaluations contained very little evidence of consultation with residents or their representatives. Also, evaluations were not comprehensive and contained the phrase “no change”. In some cases there had been “no change” in care plans since 2003. It is not usual for there to be no changes in the condition and needs of residents over such a long period, especially in relation to those receiving nursing care. There was evidence of visits by GPs when required and residents were advised and treated by other professionals. There was written evidence of hospital visits having been maintained. The nurses confirmed that the home has good GP support and that the residents have visits from the optician and chiropodist. There is also access to a dentist should this be required. The medication procedure was examined. The nurses were observed administering lunchtime medication to the residents. Medication Administration Record sheets had been completed as required and the storage of medication was found to be appropriate. Additionally, the storage and administration of controlled medication was examined and found to be appropriate. Residents spoken to were complimentary about the home and about the staff. They felt that they were treated with dignity and respect. The Poplars Nursing Home E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 Page 13 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 standard(s) 12,13,14,15 Although there is evidence that some activities are being organised for the residents, individual requests and choices are not being recorded and as a result are in danger of being ignored. The home was generally conducted so as to maximise residents’ capacity to exercise personal autonomy and choice. However this could be improved upon in relation to the provision of meals. EVIDENCE: There was an activity coordinator who was employed in the home for 21 hours per week and this was not deemed sufficient time to meet the residents needs in the home. Further hours must be provided to meet this standard. Residents’ bedrooms had been personalised and residents were able to bring in personal effects from home. Residents had their rooms organised, as they preferred. Comments received from residents included “this is my own personal space” and “ I prefer to take my meals in my own room where I can watch my TV.” The manager commented that this is the residents’ home and that their preferences must always be respected. The Poplars Nursing Home E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 Page 14 The residents are encouraged to receive visitors and those spoken to said that they made to feel welcome in the Home. Several of the residents engaged in conversation receive regular visitors to the home. In relation to meals offered and provided, these need to be improved upon. Menus offered little variety and there were some negative comments received from residents in relation to the menus. One resident stated that she had only had half a fish finger for her lunch that day together with mashed potatoes and peas. Another resident was also given the same. They stated that this was because the cook had run out of fish fingers. This was later confirmed to be true. There was mashed potatoes on the menu every day and chicken nuggets and fish fingers were regularly on the menu. Portion sizes were observed as being very conservative in size on the day of the inspection. 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 were 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. The Poplars Nursing Home E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 Page 15 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 standard(s) 16,18 The Home clearly displays it complaints procedure that is understood by residents/relatives and visiting professionals. Where residents/relatives have had areas of concern they are able to discuss these with the staff in the home, management, proprietors and ultimately the commission. EVIDENCE: An examination of the complaints book and the policy and procedure documentation, and a discussion with staff and residents, evidenced that complaints and grumbles were listened to and dealt with in the correct manner. Since the last inspection no complaints had been recorded or brought to the attention of this commission. No incidents of neglect or abuse of any kind has been reported. Documentation seen evidenced that the above issues had been discussed at length during staff induction, training and on-going supervision. The Poplars Nursing Home E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 Page 16 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 standard(s) 19,22,26 The standard of the environment within this home is in need of some improvement in order to ensure that residents are provided with an attractive and comfortable place to live. EVIDENCE: The home was generally clean and well presented throughout. Décor was attractive but in need of attention in some areas. Some of the communal areas were in need of redecorating. The home had been adapted with grab rails, ramps, a passenger lift, a stair lift, various mobile hoists, fixed bath hoists, moving and handling equipment and aids to help residents maintain mobility. One of the residents stated that she had been in the home for 7 years and would dearly like a new, more comfortable bed. The Poplars Nursing Home E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 Page 17 She stated that the metal frame hurt her legs when she was transferred out of and into bed. The same resident was also in need of a new cushion for her wheelchair. Some of the beds and bedroom furniture were in need of replacement and it is recommended that an audit of the mattresses be undertaken. The inspector spoke with one of the domestic staff who explained how the cleaning schedule is organised. The clinical room on the ground floor was being used as a storeroom for extraneous items. This must be tidied and used for the purpose of a clinical room only. The Poplars Nursing Home E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 Although staffing levels in the Home were found to be sufficient in numbers and skill mix, not all residents were receiving care commensurate with their needs. Staff were not fully trained to fully meet the needs of those in their care. This is having a direct negative impact on the care delivered. Recruitment procedures were still not correctly addressed which can compromise the protection of service users. 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 were staffed appropriately. The care manager Mrs Watson is fully supernumerary however this time has not enabled her to complete her management duties and meet all the national minimum standards. There are two qualified nurses on duty on the early shift and the late shift and one on duty for the remaining time 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 E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 Page 19 There are sufficient laundry and domestic staff over a seven-day period. There is a cook and two assistants in the kitchen daily. There is an administrator for the home who works up to 25 hours. There is also a handyman and a gardener for 20 hours per week. Recruitment procedures are still not robust enough to protect residents from abuse. The inspector examined last member of staff to be employed in the home and although she had been working for in excess of a week, there were no written references on file. This has been brought to your attention before and now needs to be addressed forthwith. A senior member of staff had signed induction booklets seen for the newest recruits. NVQ training had commenced in the home. 11 of the care staff had commenced NVQ level 2 training in direct care. This will need to be further developed to ensure that the standard target of 50 is achieved. Mandatory training is underway with the exception of regular Fire Drills. There was a lack of knowledge and skills noted by the inspectors, when attempting to ascertain whether the resident’s needs were being met. Training is required in regard to the management of Dementia and physical disability care. The Poplars Nursing Home E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,35,36,38 Financial aspects were correctly addressed and recorded with safeguards to residents. The home was reasonably well managed and some quality assurance aspects were in place. Health and safety issues had not been prioritised well and it was determined that there had not been sufficient fire drill training. Improvements need to be made in all management areas to ensure full compliance with all national minimum standards. EVIDENCE: A number of staff were spoken to at the time of the inspection. All of them confirmed that they had received regular updates in mandatory training. This included moving and handling training, fire safety food hygiene as required and COSHH. The Poplars Nursing Home E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 Page 21 However, some of the care staff/nurses had not attended sufficient fire drill training during the last twelve months. This is particularly important for staff left in charge on some shifts. The registered care manager must take into account residents and relatives views into consideration, at regular intervals. These results should be documented and avaialble at inspection when required. In bedroom number 55 there was a tripping hazard as the call bell lead was trailing all over the floor from one side of the room to the other. This resident was particularly at risk of falling over this, as she was confused and mobile. In bedroom number 50, which was situated on the second floor, the window was open about 10 inches or more, which was contravening health and safety requirements of no more than 100 mm. Accidents had been recorded and were contained within individual care plans. It was noted that, on some bedroom doors, the names of residents were missing. This is contravening fire safety requirements. It was also identified that there was some confusion amongst staff, when asked, about how many residents in total were accommodated in the home. The manager was unsure, at first, and the information board had not been updated. This knowledge is particularly important should there be a fire in the home. All care staff must receive a minimum of six formal supervisions per year and it is good practice to record such sessions, for the supervisor and supervisee to sign them and a copy kept by both. The issues which should be covered in supervision are listed in ‘Care Homes for Older People’, National Minimum Standard 36.3. Care staff at ‘The Poplars’ are now receiving more structured supervision and the progress of this will be determined on the next inspection. Some of the Health and Safety records were checked and found to be in order and well maintained. These included the records for the portable appliance testing, lift and manual handling maintenance, which demonstrated that they are regularly tested. The fire safety records were examined and fire alarm and emergency lighting testing is done at appropriate intervals. Doors must not be wedged open other than with a fire authority approved mechanisms. The Commission are still not receiving monthly regulation 26 notices and this must now be addressed. The Poplars Nursing Home E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 x 2 x x 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 3 15 1 COMPLAINTS AND PROTECTION 2 x x 3 x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 2 1 x 3 x x 1 The Poplars Nursing Home E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 Page 23 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. 2. 3. Standard 7 8 7 Regulation 15(1)(2) 15(1) 15(2) Timescale for action That care plans are reviewed with regularly and form the frame immediate work to deliver care as identified. effect That care is administered with according to the care plan. immediate effect That evaluations include the ongoing views of the resident/representative and are contained within the care plan. That individual risk assessments with are carried out before bedrails immediate are used and that consultation effect with the resident or their representative is documented. Provide, in sufficient quantities, with suitable, wholesome and immediate nutritious food which is varied effect and contains fresh produce. The programme of redecoration ongoing must include bed and bedroom furniture replacement. The extraneous items in the with clinical room must be removed immediate and the room identified as a effect clean utility. All staff must undertake ongoing adequate fire drills in line with fire authority regulations. The call bell lead must not be left with trailing over the floor in bedroom immediate Version 1.40 Page 24 Requirement 4. 7 13(4) 5. 15 16(2)(i) 6. 7. 19 19 23(2)(b) 23(2)(l) 8. 9. 38 38 23(4)(e) 13(4)(a) The Poplars Nursing Home E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc number 55. 10. 38 13(4)(a) On the second floor of the home windows in bedroom must not be allowed to open more than 100mm. Restrictors must be in place to maintain this. Bedroom doors must be identified with the name of the resident accommodated there. Managers and nurses in charge must be aware of exactly how many residents are accommodated in the home at any one time. That the staff have the skills and experience to deliver the services and care that the home offers to provide. The Commission must receive monthly regulation 26 notices from the responsible individual Further dedicated activity hours must be provided to meet the needs of the rsidents. Training is required in regard to the management of Dementia and physical disability care. Two acceptable written references must be obtained prior to employment of staff.This has been brought to your attention on the previous inspection report. Doors must not be wedged open other than with a fire authority approved mechanisms. The registered care manager must take into account residents and relatives views into consideration, at regular intervals. effect with immediate effect with immediate effect with immediate effect ongoing 11. 12. 38 31 23(4)c(iii) 23(4)c(iii) 13. 4 18(1)(i) 14. 15. 16. 17. 33 12 30 29 26 16(2)(n) 18(1 c)(i) 19(1c) Schedule 2 with immediate effect 02/09/05 ongoing with immediate effect 18. 19. 38 33 23(4)(a) 24 with immediate effect with immediate effect The Poplars Nursing Home E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 Page 25 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. Refer to Standard 8 28 Good Practice Recommendations That an audit of mattresses is undertaken with replacement as required That NVQ training is stepped up in order to ensure that the target of 50 of care staff trained to NVQ level 2 and above is attained. The Poplars Nursing Home E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Stafford - 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 E51-E09 S22360 The Poplars V242380 020805 Stage 4.doc Version 1.40 Page 27 - 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!