Inspection on 30/04/07 for The Poplars Nursing Home

This inspection was carried out on 30th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Poplars Nursing Home 07/08/09

The Poplars Nursing Home 23/02/06

The Poplars Nursing Home 04/07/05

The Poplars Nursing Home 09/03/05

The Poplars Nursing Home 16/08/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE The Poplars Nursing Home 66 South Road Smethwick West Midlands B67 7BP Lead Inspector Mrs Cathy Moore Key Unannounced Inspection 30th April 2007 07:10 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 DS0000045087.V330395.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 DS0000045087.V330395.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Poplars Nursing Home Address 66 South Road Smethwick West Midlands B67 7BP 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) 0121 558 0962 0121 558 4128 pop@carltoncaregroup.co.uk Mr A Billingham Gillian Williams Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user identified in the variation report dated 29.12.04 may be accommodated at the home in the category of PD. This will remain until such time that the service users placement is terminated or until the home can continue to meet the service users needs. 23rd February 2006 Date of last inspection Brief Description of the Service: The Poplars Nursing Home is a substantially extended property, currently registered for 35 older people requiring nursing care. The premises were originally two Edwardian houses, which were converted to provide the accommodation. The home is located close to Smethwick town centre and within easy access to local amenities including public transport. The property stands in its own grounds, with ample car parking at the front, with two tiered gardens to the rear. The communal accommodation is provided on the first floor and comprises: lounge, dining room, conservatory and quiet room. Laundry and catering are on the ground floor with a maintenance area in the basement. The service users bedrooms are located on the ground and first second floors. There are 21 single rooms, of which 6 are en-suite, and 7 shared bedrooms. There are a number of communal bathrooms with assisted bathing and showering facilities over two floors. Toilets are situated throughout the home and close to communal areas. The first floor can be accessed by a passenger lift, located off the foyer. The present scale of charges are £ 439- £500 per week. However these may be subject to an annual increase. The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced key inspection on one day between 07.10 and 17.10 hours. Prior to the inspection questionnaires were sent to the manager and service users’/ relatives for completion to gain views about the service from a range of people. Service user and relative questionnaires were completed and returned, information from these will be referenced in the body of this report. I carried out the inspection mostly in the lounge/dining area in order for observations to be made about the service given and staff involvement with the service users’. I spoke to six’ service users’, four relatives and four staff during the day. The manager was involved in the inspection throughout the day. I looked at the premises, which included; the lounges, dining room, four bedrooms, two bathrooms, ground floor toilet, laundry, kitchen and garden. I looked at medication systems and safety and records concerning for example; recruitment, training, assessment of service users’, meals, care planning and activities. What the service does well: The home has a good manager in place who is very clear of her role and responsibilities. A team of mostly established, Registered Nurses support the manager and staff. The owner of this home also has a number of other homes’ which allows support and information sharing regarding best practice with other staff and managers. The home has a stable staff group, a number have been employed for some considerable time. Staff, were extremely friendly and helpful. I saw and heard interactions and exchanges between staff and service users’ which were positive. Staff being, very polite and supportive to service users’. Staff I observed and spoke to were very motivated and proud of their achievements in terms of care provided to service users’. The home is set in large, grounds which are reasonably maintained. All staff, receive regular one to one supervision. The home has a high staff NVQ attainment level. All but one of the care staff have achieved NVQ level 2 or above. The homes’ atmosphere is positive, warm, welcoming and friendly. Visiting times are open and flexible, staff encourage service users’ to maintain contact with family and friends. The home employs an activities person three days a week. A wide range of activities are enjoyed by service users’. The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 Page 6 Food offered is of a very good standard. It gives a wide range of choice to service users’, is attractive and nourishing. The home has achieved the gold standard award for food hygiene and food provided. One service user told me; “ I am very happy here”. Another said; “ I can’t find a fault with it”. Comments received from relative questionnaires when asked ‘ what the home does well included the following: Everything. In my experience –everything. Regarding my mum she is well fed with a healthy balanced diet; kept clean and tidy and always looks smart and well groomed. Her dignity is respected and she’s treated respectively by the staff. The hygiene and cleanliness is excellent. I’m kept well and regularly informed about my mum on my regular visits. ( I usually visit at least twice a week and if mums not well everyday). Regular social activity takes place for the residents and visitors are welcomed to join in too. Staff and resident ratios seem good- there are always staff on hand who are very helpful. Sees to the residents straight away when needed, keeps them clean. The home is well kept nice and clean no complaints. I have the highest praise for The Poplars. My Mums cared for and it’s a great relief to know that if there’s any cause for concern with my mum the management would contact me immediately. The team are always welcoming to visitors at any time. There are good facilities for the residents too- hairdresser, chiropodist, optician, GP vicar (or other religious leaders) trips out for those who are able, choice of meals every mealtime. What has improved since the last inspection? An engineer to ensure that there is no risk from asbestos has surveyed the building. Chemicals and substances, which have a potential to cause harm, are now being stored more safely. Defective locks on ground floor toilets have been replaced. One double bedroom has been redecorated and provided with new lighting and carpet. The kitchen has been totally refurbished, units have been replaced with ones made of stainless steel. All staff have been trained to a high standard for dealing with dying and death. Three new night nurses have been employed. A gardener has been appointed and is due to start work in the next week or so. Our questionnaire asked relatives to tell us how the home could improve, the following comments were received; The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 Page 7 I do not know the answer to this one. I honestly can’t think of any suggestions in this area. The whole environment is very homely for the residents and very professionally run overall. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 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 DS0000045087.V330395.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Time and effort is spent making admissions to the home personal and well managed. Prospective service users’ and their families are treated as individuals and with respect and dignity for the life changing decisions they need to make. EVIDENCE: Five of five service user questionnaires received confirmed that they have been issued with a terms and conditions or contract which is positive as this document gives them information about their rights as a service user accommodated in the home, however two confirmed that they had not. When looking at the contracts on individual service user files I saw that the fee rate detailed was not accurate. These terms and conditions had been issued in 2005, yet the fee rate had not been updated for the financial year 2006/2007 which may confuse some service users’ about the cost of their placement. The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 Page 10 When I entered the home I saw that information about the home including, the last inspection report was available for all to read. In each bedroom I saw that a service user guide was available for service users to read. During the inspection I saw three people come to look around the home to possibly place a relative. I heard them and the manager discussing a possible days visit for the prospective service user, to allow them to look at the home and decide if it will be right for them. That trial visits are encouraged where possible was further evidenced. One service users’ notes read ‘11.11.05. enjoyed her visit to the Poplars. She said the staff were nice and friendly and the home had a nice atmosphere’. When I looked at service user files I saw that a record of assessment of need for each had been written. I saw that a letter had been given to each service user confirming that the home could meet their assessed needs. This evidence shows that the home has in place good pre- admission and assessment of need processes in place to enable all parties to make a decision about the suitability of the home before admission. The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have thorough care plans, which are reviewed regularly. They all have access to healthcare services. Staff, make sure that service users’ who are fit and well are encouraged to be as independent as possible. Although some improvement is needed, the home understands that safe management of medication is vital. EVIDENCE: Feedback from completed service user and relative questionnaires gave me the following information; Six of seven confirmed that the staff have the right skills and experience to look after people properly, one answered usually to this question. Six of seven confirmed that they receive the care and support they need, one answered usually to this question. The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 Page 12 I looked at three service user care plans and saw that information contained reflected their identified needs. For example; there were plans in place for diabetes, catheter and personal hygiene care. I saw that care plans are reviewed regularly and when changes occur. It is extremely positive that the home is trying to get service users and their relatives to contribute to the care planning process, this confirmed by the manager. Further, I saw on one service users file a signed form from their daughter, which states; “ More than happy with care plans that are in place”. I found that care plans and assessment records are well organised and are easy to retrieve, which is good as staff know that they can access information quickly if there was an emergency or when needed. I looked at three service user files and saw evidence to confirm that all are receiving required health care services. For example; I saw evidence to show that service users are being assessed by the continence team, that they are given the flu vaccine and that hospital visits to consultants are arranged where needed. I also saw evidence to prove that the home is reactive when problems occur for example; I read in one service user’s notes; “ I have asked. about seeing the dentist for possible dentures, but he says he does not want any dentures”. And “ I phoned the dentist about. breaking a tooth in the lower jaw”. The home is registered to provide nursing care. Registered Nurses are provided seven days per week to meet the nursing needs of service users accommodated this evidenced by rotas, observation and discussion with the manager. Generally medications are well managed. Only registered nurses administer medication in this home. One of the registered nurses has been given responsibility to oversee the medications. I saw that there was a photo on each medication record to confirm the service users identity for safer medication administration. I saw that all medication records had been signed to confirm administration, which means that service users are being given their medications. I did highlight a number of areas where improvements are needed to increase medication safety for service users’ examples of which follow; Two staff are not signing hand written medication records to confirm that the information is correct. Medication boxes are not being date labelled when opened to allow a proper audit. Medications brought into the home by individual service users’ are not being properly recorded in terms of quantity received. A number of inhalers are not being given regularly as they should for example; An inhaler had been prescribed for one service user. The instructions read ‘ Do not stop unless by Dr’. Yet the medication record had been coded with an ‘F’ which meant in this case ‘ not required’ meaning that medical instructions for this medication are not being followed. I did ask one service user if he managed his own medication he replied: “ No I’d rather them do that for me”. The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 Page 13 That the staff try to maintain privacy and dignity is evidenced in many ways. Six of seven completed service user questionnaires confirmed that ‘staff listen and act on what they say’, one answered no to this question. I observed staff during the inspection and saw positive interactions between them and service users. Staff were friendly and polite. Toilet and bathroom doors were shut when in use. One service user told me; “ They are very polite”. A relative commented: “Her dignity is respected and she’s treated respectively by the staff”. It is extremely positive that the home has taken the initiative to improve outcomes for service users’ who are at the end of their lives. All staff have received complex training and processes are in place concerning the ‘ Gold standard Framework for the end of life in care homes’. The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Central to the homes aims and objectives is the promotion of service user rights to live a meaningful life. Service users’ are offered a healthy, well balanced diet. There are choices for every meal. EVIDENCE: That the home offers flexible routines and a stimulating environment is evidenced in many ways. I saw that breakfast times are flexible in that some service users’ had their breakfast early, others had their breakfast at 10.00 hours. I heard staff asking service users’ what they wanted to do and when. One service user told me; “ We are free to come and go. I don’t usually get up until 10.30 or 11 each morning”. The home employs an activities co-ordinator who provides structured activities three times a week. The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 Page 15 Staff spoken to in a group told me; “ Activities- they are always doing something”. In the afternoon an external entertainer came to the home to sing to the service users’. I could see by their faces that they enjoyed this. It is positive that service users’ with varying needs can join in activities. I read one service users’ activity records, who has dementia and was pleased with what I read; 27.3.07 Easter activities, 10.4.07 Various activities, 24.4.07 Art and craft, 26.4.07 played bingo and won prize. Service users’ are asked about their religious needs on admission and it is determined whether or not they wished to carry on practising. One service user told me that she followed a Pentecostal faith. That she goes to pray and that preachers visit her regularly. Another service user is Roman Catholic. The manager confirmed that the home meets religious needs by ensuring regular input from religious bodies in the community. One staff member said; “ We have a lot of people come from local churches”. The home has an open, flexible visiting policy and actively encourages service users’ to maintain contact with family and friends. Visitors can be received in the lounges or service users’ bedrooms to meet their preferences. One service user told me; “ My son and grandchildren come and see me”. A visitor told me;” I visit everyday, twice a day”. Another visitor said; “ They are friendly, always offer me a cup of tea”. All service users’ are encouraged to bring into the home personal belongings to make their rooms feel ‘homely’. I saw a letter on file for one new service user to confirm that the home informs the local council that they are living at the home to ensure that they are able to vote. That service users are enabled to vote was further confirmed by the manager. Set menus are in place, which show that service users are offered a very good standard of food. Menus cover four meals a day with choices for each. I observed some of the breakfast time. Service users’ could have what they wanted. I heard the cook asking each one what they would like. Lunchtime the food smelt very appetising, was attractively served, portions were of a generous size. Beakers were in use to help service users’ drink more independently. Staff were on hand to feed and give assistance where needed. Food stocks in the kitchen were also plentiful with brand names and plenty of fresh fruit and vegetables. The kitchen assistant told me;“ Everyone here is well fed and eats well”. Some service users’ made comments about the food as follows; “ Food is good”. “ Marvellous”. The home has been awarded the Gold standard award for food and food hygiene, which is impressive. The manager told me that she is starting work soon in order to get the ‘Five for life’ healthy eating award. The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a culture that allows service users’ to express their views and concerns. Service users and others involved with the service say that they are happy with the service provision and that they feel safe and supported. EVIDENCE: The Commission has not received any complaints about this home. The home has received two complaints. Both have been investigated and addressed within a timescale of 28 days, this evidenced by speaking to the manager and viewing complaint records. A copy of the complaints procedure was on display in the entrance hall and a copy is in the service user guide which is available in each bedroom. Seven of seven completed relative questionnaires confirmed that they know how to make a complaint. Seven of seven completed service user questionnaires confirmed that they know who to speak to if they are not happy. There have been no recent concerns, allegations or incidents of abuse. This confirmed by, records, staff and management. I asked a number of relatives if they have ever seen anything concerning when visiting the home for example; staff behaviour, shouting, all answered “no”. The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 Page 17 I asked staff what they would do if a service user told them that they had been hit. All told me that they would report this immediately to the person in charge or manager. One staff member said; “ If anything like that happened I would leave, I would not want to work here”. Staff were able to describe to me the different forms of abuse that could occur, demonstrating this their awareness. All staff have received abuse awareness training. A number do need refresher training as their certificates say ‘valid for one year’ which were issued in 2005. Sandwell protection procedures were available within the home. The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment, which, is safe and comfortable but is in need of redecorating and replacement of carpets and furniture. Service users’ may benefit if more single rooms and en-suite facilities were provided. EVIDENCE: The home provides a safe and comfortable environment. Communal areas are spacious comprising of a large and smaller lounge, dining areas and a conservatory. It is evident that the owner has identified that the home has considerable redecorating needs as the decorators were on site during the inspection. They are in the process of redecorating the lounge, dining and conservatory areas. Air conditioning is being provided in the conservatory. The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 Page 19 The home is ‘ shabby’ in a number of areas, such as landings and corridors. I saw damaged wallpaper and paintwork and carpets that are well past their best, not giving the confidence that the premises are well maintained. The home has a relatively high number of ‘shared’ or double rooms and a low number of en-suite facilities. The manager told me that plans are in place to hopefully build two new bedrooms then the number of double rooms can be decreased. Service users’ I spoke to however, were happy with their rooms. One occupying a double room said; “ yes, my room is alright”. Another said; “ I like my bedroom”. The home was clean and free from any odour. One relative said; “ There is never any smell like in other places”. Staff said; The home is always clean, there is no smell”. Six of seven completed service user questionnaires confirmed that ‘the home is always fresh and clean’, one answered usually to this question. I saw that there was a lot of bedding stored in the laundry. The manager told me that this was no longer used. It should be removed as it could be an ideal place for bacteria to live and grow. All staff have either received infection control training or have been booked onto training which should give them the knowledge to prevent infection outbreaks in the home. The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has staff at all times to support the needs of service users’ and has a proactive training programme. The service has a fairly good recruitment programme but needs some ‘ fine tuning’ to further enhance service user safety. The recruitment of good quality staff is very important to the home. Staff have received the required training to ensure that service users’ are in safe hands. EVIDENCE: The home is registered to provide nursing care which means that a registered nurse must be on duty at all times. That registered nurses are provided at all times is evidenced by rotas and confirmed by the manager staff and observation during the day. Staffing is provided as follows: AM- Seven carers and one registered nurse. PM- Five carers and one registered nurse. An additional carer is provided between 17.00 and 21.00 hours as this is a busy time. Nights -Three carers and one registered nurse. Cooks, laundry and domestic staff are also provided. The manager is on site Monday to Friday and other times if required. The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 Page 21 I observed during the inspection and did not see any service user having to wait for anything. Staff were available to give assistance for toileting, personal care and feeding. It was nice to see that staff had time at intervals during the day to speak to service users’. Service users’ seen during these times enjoyed the attention. The manager confirmed that staffing levels are adequate and told me they can be raised or lowered as needed. All staff spoke to confirm that there is enough staff provided to meet the needs of the service users’. Service users’ and families spoken to also felt that staffing levels are adequate. Staff observed were, friendly, helpful and polite when dealing with the people in their care. They gave service users’ choices at meal and other times. One relative described the staff as; “ Friendly and helpful”. One service user said; “ Staff are very pleasant, very nice and very polite”. It is very impressive that all but one staff member has achieved NVQ level 2 or above in care meaning that staff have the skills and knowledge needed to ensure, that service users’ are in safe hands. Recruitment practices generally are of an adequate standard. I saw that each staff member had completed an application form, that two written references had been obtained and that a Criminal Records Bureau (CRB) check had been completed. However, a number of shortfalls were identified which need to be addressed to ensure that recruitment processes are completely safe and sound as follows; the last three nurses employed had been appointed before their full CRB had been obtained which could leave the home vulnerable. Passports had been accepted as two staff members’ identity, yet these had expired. I saw evidence to confirm that both carers and registered nurses complete induction training which means, they are provided with the correct information and knowledge for them to do their work. The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The registered manager has the required qualifications and experience, is highly competent to run the home and meets its stated aims and objectives. There are processes in place for monitoring practices, staff receive regular, formal supervision and working practices are safe. EVIDENCE: The manager has been employed by the home for at least five years. She is a level 1 Registered Nurse and has achieved her NVQ level 4 in management. The manager is clear about her role and responsibilities and remains focussed and motivated. The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 Page 23 Staff spoken to confirmed that she is an efficient manager and that they feel comfortable in approaching her for help and support. Records showed that the home has various ways to monitor its functioning. The manager showed me a new system that has recently been introduced for ‘self audit’ assessment’ purposes. I saw minutes of staff and service user meetings. Staff spoken to confirmed that they attend meetings regularly. The home uses service user, relative and staff questionnaires to measure satisfaction or other. I was provided with the analysis from these. The manager told me that she has told relatives that she will be available certain evenings so that they can approach her to answer their questions and this gives them further opportunity to voice their views about the home. The general manager for the organisation visits the home at least weekly to assess the service provided and gives supervision to the manager. I checked three service users’ money held in safe- keeping which I found to be correct against written balances. Receipts were available for all transactions. Two signatures confirmed each transaction. I was very impressed when I viewed staff files to see evidence of regular one to one supervisions and appraisals. Staff spoken to confirmed; “ Yes we have regular supervisions”. I looked at health and safety records and service certificates for equipment, these were all in order. I saw the following; Fire drills ‘All staff’ 26.2.07. Fire alarm, emergency lighting and fire fighting equipment services 6.10.06. Water bacterial test 23.1.07 and lift service 20.4.07. The manager keeps records of all accidents and analyses these on a monthly basis. I looked very briefly at the kitchen as Environmental Health carried out a full inspection in 10/06 their report said; “ Verbal advice only no action needed”. The home has had a new stainless steel kitchen installed. I did not that one jar of sauce did not have a lid and another was past its ‘shelf life’. These issues were highlighted to the manager during the inspection. The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 Page 24 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 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x 2 x 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 3 4 x 3 The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 13(2) Requirement All medication bottles and packets must be date labelled when opened to enable effective auditing. Where service users are not taking their regularly prescribed inhalers then a referral must be made to their doctor for possible review. To increase medication safety all medications received into the home must be counted and recorded with the date detailed of receipt. Where a variable dose is prescribed then the amount administered must be recorded. Timescale for action 15/05/07 2 OP9 13(2) 15/05/07 3 OP9 13(2) 15/05/07 4 OP9 13(2) 15/05/07 The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 Page 26 5 OP29 19 Recruitment processes must be enhanced to increase safety as follows: Registered Nurses should not be allowed to commence employment on POVA first. Passports and other documents should only be accepted for identity purposes if they are in date. Where registered nurses work elsewhere they should be asked to provide a list of days/ hours worked each week. 20/05/07 The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP2 OP9 OP9 Good Practice Recommendations Service user terms and condition / contract documents should be updated every year to reflect the current fee. It is strongly recommended that the security of the medication room is reviewed. It is strongly recommended that where medication records are hand written that 2 staff sign to confirm the transferred information is correct. Abuse training should be repeated for staff whose certificates stated valid for 1 year (in 2005). The owner must continue with the redecorating programme. It is strongly recommended that this is treated as a matter of priority. Plans should include: The decrease of double rooms and the increase of en-suite facilities. The levelling of all floors in landings and corridors to prevent risk. The provision for additional storage- numerous wheelchairs in the lounge. 4 5 OP18 OP19 The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Poplars Nursing Home DS0000045087.V330395.R01.S.doc Version 5.2 Page 29 - 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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