CARE HOMES FOR OLDER PEOPLE
The Poplars Nursing Home 66 South Road Smethwick West Midlands. B67 7BP Lead Inspector
Jean Edwards Announced 4 July 2005 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 E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service The Poplars Nursing Home Address 66 South Road Smethwick West Midlands. B67 7BP 0121 558 0962 0121 558 4128 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) Mr. A. Billingham Mrs Gillian Williams Care Home 35 Category(ies) of OP (Old Age) 35 registration, with number of places The Poplars Nursing Home E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Date of last inspection 09/03/05 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 Home has a staff team of 43 people, including the Registered Manager.
The Poplars Nursing Home E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection visit was undertaken by the inspector from the Commission for Social Care Inspection using the following information: the action plan submitted by the home to the unannounced inspection in March 2005, reports from the organisation relating to the conduct of the home, the pre-inspection questionnaire and records held at the home. The visit commenced at 9:30 am and lasted until 5:20pm. During the visit the inspector spoke to the majority of residents who are currently living at the home, with longer discussions taking place with the residents whose care was looked at in depth. The Group Manager, Registered Manager and Deputy Manager took an active part in the inspection process. Survey comment cards were sent to the residents and relatives from the Commission for Social Care Inspection (CSCI), 21 have been returned. Comments are generally very positive, for example making favourable comparisons with previous homes, stating that information is good and staff are caring. The inspector toured the building, looking in particular at the kitchen, laundry, bathing facilities, communal areas of the home and a sample of residents’ bedrooms, with their permission. What the service does well: The registered manager, supported by the organisation, has responded to the previous inspection report with a comprehensive action plan, which gave dates for the required improvements to be put into place. All improvements from the last inspection visit are now in place. Information about the home and the service it provides is readily available on the premises and on its Internet web site. A relative commented, information about the home is comprehensive, the assessment by the registered manager was very thorough and realistic, further comments are, staff keep me informed of hospital visits and any concerns, and very welcoming, so impressed with teamwork - very together.
The Poplars Nursing Home E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 Page 6 The manager and staff make sure that each resident and as appropriate their relatives are involved in the plan of how their care is to be provided. The home also has excellent relationships with the local GP and other health care services, which provide support for the residents at The Poplars. Residents are encouraged by staff to treat The Poplars Nursing Home as their own home and to be as independent as their disabilities allow. Residents are able to make their own choices and can take an active part in meetings and surveys if they wish. Views can be freely aired about the running of the home. Comments are, its a marvellous place - couldnt be bettered, very good, best place I could find and want to stay here for good. People who are able are encouraged to spend some of their time with a range of stimulating activities supported by the activities co-ordinator and staff. There are organised activities and outings, such as pub lunches. Some people are able to continue with their individual interests in the wider community. One resident states that he is still able to attend his local church, where he was baptised, married and had his children baptised; and the vicar visits him at The Poplars. Comments from relatives are, family is impressed with support and stimulation - done sensitively, and being able to have communion is very important to my mom. Other people may choose not to be involved in organised activities, decisions that are fully supported. The meals are thoughtfully and well prepared, and the menus are pre-planned and each persons preferences are recorded each day. In addition members of staff were seen to ask residents what they preferred at each mealtime. Special diets are prepared and served in a way, which tempts people to eat. A member of staff is on hand for each table and is able to sensitively offer people help and assistance, as they need it. The Poplars now has a stable group of staff who have worked at the home for some time and know the residents well. They are caring, committed and flexible, often willing to work extra shifts, especially to support residents with outings in trips away from the home. Residents and visitors spoken to described the home as ‘happy’, ‘friendly’, ‘ welcoming’ and ‘well run’. Staff are described as professional, genuinely caring and very good here, and brilliant team - with professional respect for each other. There was a lot of friendly banter between staff and residents throughout the day. During the visit staff demonstrated a dedicated approach to their work; they clearly know residents’ likes and dislikes and how to meet their needs. They are keen to share views and answered any questions in an open and honest manner. The Poplars maintains excellent standards of cleanliness. The home is tidy, homely and comfortable. A relative commented that she is very impressed with the standards of hygiene.
The Poplars Nursing Home E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 Page 7 This inspection was conducted with full co-operation of the Registered Manager, staff and residents. The atmosphere through out the inspection was relaxed and friendly. The Inspector would like to thank staff, and residents for their hospitality during this inspection visit. What has improved since the last inspection? What they could do better:
Generally comprehensive assessments relating to residents needs are carried out, however on a small sample of residents records, there are minor omissions. Examples are that the risk of residents falling must always be assessed and recorded; and each person must be weighed on consistent basis.
The Poplars Nursing Home E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 Page 8 The home must make sure that inventories of personal property are always completed, signed and dated. The organisation must plan a date for the refurbishment of the main kitchen as priority and renovate the damaged flooring as an interim measure. This required improvement is outstanding from the previous inspection visit. The organisation must revise and update the staff contract of employment so that staff understand the implications of the Register relating to the protection of vulnerable adults. There are a small number of improvements, which the home must make to fully comply with health and safety legislation. For example staff must make visual checks on slings used with the hoists on a regular basis and make a record of their findings. 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 E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 Page 9 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 E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 Page 10 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) 1,2,3,4,5 Information about the running and performance of the home is made proactively available and residents are encouraged to make their views known. The home has updated contracts/terms and conditions of occupancy, this has the effect that residents and their advocates have good information regarding their rights and entitlements and any agreed restrictions. The home uses comprehensive assessment tools, which means that residents’ needs are thoroughly assessed to ensure that care needs will be met. Introductory visits and trial stays are encouraged by the home, ensuring that people have time to make decisions, which are right for them. This home does not provide intermediate care. EVIDENCE: The Registered Manager and Group Manager have revised and updated the homes statement of purpose and service user guide, which are now produced in an attractive format. There are copies in the reception area and there is
The Poplars Nursing Home E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 Page 11 evidence from discussions with families that information about the home is given to them. Each person has a contract / terms and conditions, which is appropriately signed and dated. The contract / terms and conditions has been revised and updated taking account of the Office of Fair Trading publication Unfair Terms in Care Homes Contracts, as is good practice. Examination of a sample of residents’ case files demonstrates that the home has obtained the referral agency’s assessment of needs and in most cases a care plan. There are copies of Sandwell Authority’s single assessment information for people admitted from the Sandwell area. In addition the home has a comprehensive assessment tool, which is comprehensively completed with all relevant information. Evidence from informal discussions with residents and families is that the home does offer an opportunity to visit before an admission takes place. Most prospective residents are too frail to take the opportunity to visit; they are reliant on their relatives to make the choice. There is documentation relating to introductory visits on each persons case file. The Poplars Nursing Home E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 Page 12 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 is a clear and consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet service users needs. The health needs of residents are well met with evidence of good multi disciplinary working taking place on a regular basis. The home has made good progress to improve the arrangements for administration of medication, which safeguards the well being of people living at the home. EVIDENCE: There is a very detailed and comprehensive care plan in place for each person, based on his or her assessed needs. There is good evidence that care plans are developed in conjunction with the resident and their relatives, with signatures in place to indicate agreement. The manager has made great improvements to care plans for people with Diabetes and other complex needs. There give staff explicit guidance about the monitoring arrangements for diet, skin, eye and foot care. On the sample of residents’ care plans there are records of the persons preferences for their daily routine, for example rising, retiring, and bathing. The Poplars Nursing Home E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 Page 13 There are generally good risk assessments in place and appropriately recorded health care screening assessment tools completed for each person. However on one recently admitted residents case file (DD) there are no documented falls risk assessment or risk assessment for the bedrails, which are in use. There is generally satisfactory evidence that residents are weighed on admission and regularly weighed each month. However there are no recorded weights for one person (MJ), whose care has been assessed at this visit. Documentation relating to the health care checks provided for older people are satisfactory to demonstrate that all regular checks have been offered, whether or not they had attended or what the outcome has been. Record sheets for health review, dentist visits, optician visits, chiropodist visits, medication reviews are available on the sample of residents case files assessed. There is good evidence of satisfactory nutritional and fluid intake, one person recently admitted has an improved appetite and is attempting to feed herself. Improvements noted by her family. It is positive that jugs of cold drinks are available in communal areas and bedrooms, staff ensure that all residents have a good intake of fluids, with a range of drinks proactively offered throughout the day and night if required. There are good recording systems where people are deemed to be nutritionally ‘at risk’. There is a comprehensive medication policy and procedure. As good practice this is regularly reviewed and updated, with staff signatures to demonstrate their awareness and compliance. Medication administered by the Deputy Manager during the visit was observed to be given in a particularly sensitive manner, taking time to sit beside a resident with dementia, to encourage her to drink her liquid medicine. Completion of medication records (MAR sheets) has generally improved and monitoring arrangements of stock levels demonstrates improved practice. There is ample evidence that support is given to residents to be appropriately groomed and dressed. There are records of each person’s preferred name, and all staff address residents in a respectful manner. Each person is seen to be supported in ways, which maintain their personal dignity. The Poplars Nursing Home E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 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 standard(s) 12,13,15 This home makes planned and spontaneous activities available on a regular basis, even though not all residents are able to take advantage of socially stimulating opportunities. There is good contact maintained with family and friends for the majority of residents. The meals at The Poplars are good, offering both choice and variety and catering well for special dietary needs. EVIDENCE: Residents spoken to confirm that they feel that there are generally sufficient staff on duty and that they have time to spend talking to them and to enable them to enjoy regular activities and outings, according to choice. The home employs an activities co-ordinator and there is a weekly activities programme, which is published. There is a range of social and spiritual stimulation available, such as a monthly church service at the home, though a least one person attends his own church; mobility plus - exercises at the home; and other entertainers brought into the home at least three times each month as well as social evenings. In addition those people well enough are able to enjoy trips and outings, for example sampling local pub lunches. The Poplars Nursing Home E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 Page 15 There is evidence available to demonstrate that the staff consult with all residents as to their preferred activities, hobbies, and outings, with documented preference and the comprehensive activities programme. There is a visiting policy, which welcomes visitors. A considerable number of people visited during this visit. One person made a special effort to talk to the inspector to express her appreciation of the way her mother is cared for. The home has a 4-weekly menu, which offers a wide and varied choice of meals. The menus are displayed on each table in the dining room and care is taken to record each persons daily preferences. Catering staff take a pride in presenting the food to look appetising, even pureed and soft foods are presented separately on the plate. Care staff were seen to offer sensitive assistance to people needing help or feeding. The Poplars Nursing Home E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 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 standard(s) 16,17,18 The home has a satisfactory complaints system with good evidence that residents and relatives feel that their views are listened to and acted upon. Arrangements for protecting residents are satisfactory safeguarding them from possible risk of harm or abuse. EVIDENCE: The Home has a complaints procedure, which is displayed in the reception area and contained in the service user guide. The home has had one complaint in the past twelve months, which has been satisfactorily resolved, within the 28 day timescale. The Home has a copy of the Local Authority multi-agency Adult Protection policy and procedure. The Home has developed its own policies and procedures relating to the protection of vulnerable adults, dealing with aggression, use of physical / non-physical intervention; whistle blowing, dealing with residents finances and there is a copy of the Public Disclosure Act available. The manager continues to regularly raise staff awareness of non-physical intervention strategies through supervision sessions and training. There are records to demonstrate that all staff have attended a one-day training course relating to abuse. The Poplars Nursing Home E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 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 standard(s) 19,21,24,26 The standard of the décor within this home is very good with evidence of improvement through continuous maintenance. This is a homely and comfortable environment for residents. The Poplars has effective systems in place to ensure sources of potential infection are controlled. EVIDENCE: The Poplars Nursing Home, originally two Edwardian houses, is a substantially extended property, currently providing accommodation for up to for 35 older people requiring nursing care. The home has undergone major refurbishment over the past two years, since the change of ownership to the current Registered Proprietors. The décor, fixtures and furniture are completed to high standards. The property stands in its own grounds, with ample car parking at the front, and tiered, well-tended gardens to the rear. The Home has 5 communal bathing / showering facilities located on the ground and first floors in addition to the en suite facilities in 7 bedrooms. There are assisted baths suitable to meet the current needs of the residents. The
The Poplars Nursing Home E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 Page 18 redecorated bathrooms are tastefully completed to provide a pleasant bathing experience for residents. In addition to the en suite facilities there are a number of communal toilets situated throughout the home, close to communal areas. During the tour of the premises a sample of residents’ bedrooms were viewed, with their permission. These are furnished appropriately according to the needs of each person. The bedrooms are tastefully decorated and it is evident that people are encouraged to personalise their rooms with their own possessions, pictures, mementos and furniture. Although there is an inventory in place documenting personal possessions, furniture etc., brought into the Home, held on each person’s case file, not all were complete, signed and dated. During the tour of the premises on this visit, it is evident that high standards of cleanliness continue to be maintained and there were no discernable malodours. The laundry is separately staffed; the person spoken to takes great pride in being well organised. There are two industrial washing machines and two tumble driers and new ironing press. Good infection control measures are in place. The homes main kitchen is in good order, clean and tidy and well organised. A new fridge, freezer and dishwasher have been provided since the last visit, improving food safety. Appropriate food hygiene/safety measures are in place; the registered manager regularly monitors these. The kitchen area has not been refurbished; additionally the badly scored kitchen floor near the refrigerators has deteriorated. This is an outstanding requirement from the previous inspection visit and must now be included on the homes refurbishment programme with an identified timescale, as a priority. The Poplars Nursing Home E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 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 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 Good progress has been made over the past two years in addressing substantive staffing levels and residents now receive consistent care. The standard of vetting and recruitment practices is good, with all appropriate checks being carried out. Staff morale is high resulting in an enthusiastic workforce working positively with residents to improve their whole quality of life. Good progress is being made to provide all staff with training, which provides safeguards for residents. EVIDENCE: Assessment of staffing rotas demonstrates that the home continues to maintain satisfactory staffing levels. The registered manager reviews staffing levels regularly on a monthly basis, using Department of Health Residential Forum Staffing Tool, taking account of the occupancy and dependency levels of residents accommodated, as is good practice. The Home has a staff team of 41 people including 25 care staff, 4 catering staff, 2 domestic staff, 2 laundry staff, 1 activities co-ordinator, 1 gardener 1 maintenance staff, 1 administration staff, 4 first level nurses and the Registered Manager. The staff team is now relatively stable. Four staff have left the home’s employ in the past 12 months, for valid reasons. There are currently no staff vacancies. The Poplars Nursing Home E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 Page 20 The Home continues to make progress to ensure that there is a strategy to meet the requirement of the standard of 50 of care staff trained by the end of 2005. Currently 26 of care staff have achieved the NVQ 2 award in care, with a further tranche of care staff registered as candidates to complete the training. The Home operates robust recruitment practices. Random samples of staff files examined are satisfactory. Interview questions and answers should be retained on staff personnel files as a matter of good practice. The Poplars Nursing Home E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 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 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) 31,33,37,38 The registered manager is supported well by her nurses and senior staff in providing clear leadership throughout the home, with staff demonstrating an awareness of their roles and responsibilities. The systems for resident consultation at The Poplars are good with a variety of evidence that indicates that residents’ views are both sought and acted upon. EVIDENCE: Ms Gill Williams has been the Registered Manager at The Poplars since the change of ownership of the home in July 2002. She is a RGN (Registered General Nurse), with an NVQ 4 Award, Registered Managers Award (RMA), specialist nurse training ENB941: Care of the Elderly and ENB931: Care of the Dying; and she holds the NVQ Assessors Award. She has many years of nursing experience, including the management of nursing homes. It is evident that she continues to update her training and personal development. The Poplars Nursing Home E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 Page 22 There is an annual development plan for the Home, with continuous self monitoring, evidencing the involvement of residents, representatives and other community stakeholders. The Local Authority has approved this quality assurance system, monitored by the group manager. The Investors in People (IiP) organisation visited the home in March 2005 to conduct interviews as part of the process for the home to achieve the Award. The Poplars has now achieved The Investors in People (IiP) Award. This success was recently celebrated with the residents, families and staff. Record keeping at the home continues to improve, achieving high standards, with only very minor improvements required at this visit. All personal information is held, stored and disposed of in accordance with the Data Protection Act 1998. A sample of mandatory training records, fire safety and maintenance documentation examined is satisfactory. The Manager ensures that all staff receive mandatory training commensurate with their roles; fire training, drills twice each year, moving and handling, first aid, food hygiene, health and safety and infection control training, commensurate with duties undertaken. The accident records examined are satisfactory. There have been 12 accidents involving residents since March 2005, which is a reduction. The Manager undertakes a regular documented accident analysis each month, which is used to identify trends and instigate reviews / reassessments and corrective action as required. Minor health and safety issues raised are: although the pharmacy has supplied oxygen storage notices, these may not be adequate and clarification must be sought that the oxygen notices supplied are correct warning notices. Although the home undertakes a range of health and safety checks, these do not include regular visual checks of slings used with hoists. Sling checks must be added to the schedule of regular documented checks of equipment. The Poplars Nursing Home E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 4
COMPLAINTS AND PROTECTION 2 x 3 x x 3 x 3 STAFFING Standard No Score 27 3 28 2 29 3 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 3 x 3 x x x 2 2 The Poplars Nursing Home E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 8 Regulation 13(4) Requirement 1) To complete a falls risk assessment for DD. Timescale for action 31/07/05 2. 3. 4. 8 14 19 26 13(1) 17(2) 23(2) 2) To complete a bedrails risk assessment in relation to DD To ensure MJ is weighed with 31/07/05 weight monitored on a regular basis To complete the inventory for 31/07/05 DD, ensuring all inventories are signed and dated 30/09/05 To provide the Commission for Social Care Inspection with a detailed and comprehensive action plan to include timescales for action for the following areas: 1) To include the refurbishment of the homes kitchen in the maintenance/refurbishment programme within an identified timescale (Timescale of 31/05/05 Not Met) 2) To make good the area of flooring in the kitchen which has been damaged, as an interim measure (Timescale of 31/05/05 Not Met) To revise and update staff 31/08/04 contracts to include references to
Version 1.40 Page 25 5. 29 17(2) The Poplars Nursing Home E55 S45087 The Poplars NH V231901 040705 Stage 4.doc 19(1) 6. 38 13(4) abuse / gross misconduct and the potential for referal to the POVA Registers To undertake regular and documented visual checks of slings 31/08/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 9 20 29 Good Practice Recommendations That up to date accredited medication training be provided for all staff involved in the administration of medication including trained nurses That clarification is sought that the oxygen notices supplied by the pharmacy are correct H & S warning notices That interview questions and answers are retained on staff personnel files The Poplars Nursing Home E55 S45087 The Poplars NH V231901 040705 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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