Inspection on 23/06/05 for The Poplars Residential Home

This inspection was carried out on 23rd June 2005.

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 Residential Home 08/10/08

The Poplars Residential Home 24/10/07

The Poplars Residential Home 05/12/06

The Poplars Residential Home 04/10/05

The Poplars Residential Home 09/11/04

The Poplars Residential Home 05/05/04

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE The Poplars Residential Home Watling Street Mountsorrel Loughborough LE12 7BD Lead Inspector Everton Osbourne Unannounced 23 June 2005 09:30 rd 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 Residential Home v233587 c51 c01 s55876 the poplars residential home v233587 230605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Poplars ResidentiaL Home Address Watling Street Mountsorrel Loughborough LE12 7BD 0116 230 2102 0116 230 4485 None Mrs Sayida Mawani 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) Mrs Julie Ridding Care Home 21 Category(ies) of DE(E) Dementia - over 65 (4) registration, with number MD(E) - over 65 (4) of places OP Old Age (21) The Poplars Residential Home v233587 c51 c01 s55876 the poplars residential home v233587 230605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1) No persons falling within category MD(E) (Mental Disorder over 65 years of age) or DE(E) (Dementia over 65 years of age) may be admitted to the home when 4 persons in total of these categories/combined categories are already accommodated within the home. Date of last inspection 9th November 2004 Brief Description of the Service: The Poplars care home cares for twenty-one older persons who have dementia and a mental disorder in a purpose built property situated in the village of Mountsorrel. The home is close to the market town of Loughborough where residents have access to a variety of facilities. The home is easily accessible for private and public transport.The premise consists of two floors accessible by use of the stairs and passenger lift. There are a variety of facilities in the home including dining and lounge space. The home comprises seventeen single bedrooms, two without ensuite facilities. There are two double bedrooms with ensuite facilities. A garden is situated to the rear of the premises. The Poplars Residential Home v233587 c51 c01 s55876 the poplars residential home v233587 230605 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took five hours and thirty minutes to complete. The outcome of the inspection was positive in that two residents spoken to indicated that they are satisfied that the home is attending to their care needs. Two staff members were spoken with as part of the inspection process. The registered manager and one of the proprietors were also spoken with. Prior to this inspection a person who wished to remain anonymous made a complaint about the level of care provided in the home. This inspection took into account the allegations made against the home and inspected the Standards relating to the issues raised by the complainant. The following are issues brought to the attention of the Commission for Social Care Inspections: 1) 2) 3) 4) 5) 6) 7) Fridges not working properly and poor cleanliness in the home Poor food quality and insufficient resources for heating water for hot drinks Inadequate staffing levels Care plans not reflecting residents’ care needs Staff member age 19 years left in charge of shifts Resident with MRSA and dementia not recorded in care plans Resident with a specific behavioural problem not recorded in the care plan Outcomes for the issues raised are recorded in the main body of this report. What the service does well: What has improved since the last inspection? No issues were identified during this inspection. The Poplars Residential Home v233587 c51 c01 s55876 the poplars residential home v233587 230605 stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Poplars Residential Home v233587 c51 c01 s55876 the poplars residential home v233587 230605 stage 4.doc Version 1.30 Page 7 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 Residential Home v233587 c51 c01 s55876 the poplars residential home v233587 230605 stage 4.doc Version 1.30 Page 8 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 and 4 Robust admission and assessment processes are in place for the care and protection of residents. EVIDENCE: An examination of the Statement of Purpose indicated that the document contains sufficient information about the services the home provides. Two residents’ admission records seen indicated that a contract of residence is given to them outlining the Terms and Conditions of their residency in the home. Two residents’ assessments seen indicated that accurate description of their care needs is written in the documents, which was confirmed by verbal statement made by one of the resident. Comments from two residents about their care needs being met in the home is positive for example one resident stated ‘I’m looked after well’. Observation made of one resident being transferred from an armchair to wheelchair using a hoist was carried out safely by two care staff members. The Poplars Residential Home v233587 c51 c01 s55876 the poplars residential home v233587 230605 stage 4.doc Version 1.30 Page 9 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 and 10 The care plan process works well in ensuring that residents’ social and health care needs are met appropriately. Insufficient information in one care plan has the potential of placing staff members at risk of harm. Residents are treated well and the medication process good in ensuring that residents receive their medication as prescribed. EVIDENCE: Two residents care plans were examined. The documents seen are reviewed on a monthly basis and have information that gave good guidance on how to meet the residents’ care needs. There was insufficient information in one resident’s care plan regarding the risks to staff members when having contact with this resident. The registered person is required to ensure that all relevant information regarding risks to safety is written in all care plans for the protection of staff members and other residents. The allegation that insufficient information is in the care plan regarding specific behavioural problem is upheld. The allegation that changes to care needs are not recorded is not upheld The Poplars Residential Home v233587 c51 c01 s55876 the poplars residential home v233587 230605 stage 4.doc Version 1.30 Page 10 Two residents spoken with indicated that they have good access to General Practitioners and Community Nurses. Two residents’ daily care records seen indicated that health care professionals such as General Practitioners and Community Nurses visit the home in order to provide medical and nursing care when required. The medication process was observed which indicated that the process is being carried out safely and in accordance with their written medication policy. This policy was inspected and found to have adequate information for staff guidance when administering medication to residents. Two residents indicated that they receive their medication at the times required. Their medication records were up to date. Observations made indicted that residents’ privacy is being maintained in the home for example staff members were seen knocking on residents’ bedroom doors before entering the rooms. Seventeen comment cards from residents seen were all positive regarding their privacy and respect in the home. Two care plans were found without residents or their relatives’ signature to indicate that they were involved in the care plan process. The registered provider should involve residents or their relatives in the care plan process and obtain signatures where possible. The Poplars Residential Home v233587 c51 c01 s55876 the poplars residential home v233587 230605 stage 4.doc Version 1.30 Page 11 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) 13, 14 and 15 Residents’ choice in the home and contact with the community is managed well so that residents have control of their lives and maintain contact with relatives and friends. Meals are good and varied in meeting residents’ nutritional needs. EVIDENCE: Two residents indicated that meals are varied and wholesome and that daily choice is given. The menu and lunchtime meal seen confirmed the residents’ verbal statements. One resident commented ‘Meals are okay’. The residents spoken with also indicated that regular cold and hot drinks are served throughout the day. Observation of the afternoon drinks being made and served indicated that residents were satisfied with the process. The allegation that meals are of poor quality and that insufficient drink making facilities are in the home is not upheld. Two residents spoken with indicated that they have choices everyday regarding their daily activities, which includes choices concerning when to have visitors in the home. The visitors record and relatives seen in the home at the time of the inspection confirmed that residents are able to maintain contact with the community. The Poplars Residential Home v233587 c51 c01 s55876 the poplars residential home v233587 230605 stage 4.doc Version 1.30 Page 12 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 and 18 Complaints and adult protection are managed well for the protection of residents residing in the home. EVIDENCE: Detailed examination of the written complaints and adult protection procedure indicated that good information is provided for staff members’ guidance. Prior to this inspection a person who wished to remain anonymous made a complaint about the level of care provided in the home. The following are issues brought to the attention of the Commission for Social Care Inspections: 1) 2) 3) 4) 5) 6) 7) Fridges not working properly and poor cleanliness in the home Poor food quality and insufficient resources for heating water for hot drinks Inadequate staffing levels Care plans not reflecting residents’ care needs Staff member age 19 years left in charge of shifts Resident with MRSA and dementia not recorded in care plans Resident with a specific behavioural problem not recorded in the care plan Two staff members spoken with gave good verbal responses concerning how to prevent elder abuse and what to do should there be suspicion or alleged case of abuse occurring in the home. The Poplars Residential Home v233587 c51 c01 s55876 the poplars residential home v233587 230605 stage 4.doc Version 1.30 Page 13 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, 20, 21, 22 and 26 The home is maintained to a good standard with an emphasis on creating a homely environment. Adequate communal space and facilities are provided for residents’ comfort. EVIDENCE: Observations made during the inspection indicated that the flooring, walls and fixtures are maintained to good standards. One resident stated ‘It’s okay’, referring to the décor and cleanliness of the home. The bathroom and toilet facilities were inspected and found to be sufficient in numbers based on the number of residents residing in the home, which include adequate communal space such as the lounge and dining area. The Poplars Residential Home v233587 c51 c01 s55876 the poplars residential home v233587 230605 stage 4.doc Version 1.30 Page 14 An inspection of the premises found it to be clean and hygienic in appearance. Two staff members spoken with gave good verbal responses concerning suitable hygiene practices for example good hand washing techniques. The infection control policy seen had adequate information for staff members’ guidance concerning good hygiene practice. Observations made indicated that safe systems are in place for the prevention and control of infectious disease. An inspection of all fridges in the home found them to be clean and in good working order. The kitchen cleaning logbook and maintenance records indicate that the fridges are cleaned everyday and that all equipments kept in the home are regularly maintained. The allegation that fridges are not working is not upheld. The Poplars Residential Home v233587 c51 c01 s55876 the poplars residential home v233587 230605 stage 4.doc Version 1.30 Page 15 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 and 30 The number of staff competent and employed to work in the home is sufficient to meet residents’ daily care needs. EVIDENCE: Observations made during the inspection and the staffing rota seen indicated that suitable skill mix and the number of staff on duty is sufficient for attending to residents in the home. Two residents’ comments concerning the availability of staff members is positive, indicating that a care staff is available when needed. An inspection of two weeks staffing rota indicated that sufficient staffing levels are provided in the home. The allegation that there are insufficient staffing levels in the home is not upheld. Conversation held with one care staff member and her records seen indicated that she is suitably experienced and qualified to work in the home. The allegation that a staff member aged 19 years old is left in charge without suitable supervision is not upheld. The Poplars Residential Home v233587 c51 c01 s55876 the poplars residential home v233587 230605 stage 4.doc Version 1.30 Page 16 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) 33, 37 and 38 Residents’ care records and fire safety is well managed for residents’ protection. Good quality control processes are in place to obtain residents’ views about the care they receive. EVIDENCE: Two residents’ care records were inspected. Good recordings are kept of residents’ daily care needs. The medication records and assessments were all up to date and kept in good order. Care plans were generally up to date with the exception that residents or their relatives’ signatures were not on the documents to indicate that they have been a part of the review process. Observations made indicated that fire safety equipment for example fire extinguishers are examined on a regular basis. Conversation held with the deputy manager indicated that regular testing of the fire safety alarm is carried. A record of this was seen. The Poplars Residential Home v233587 c51 c01 s55876 the poplars residential home v233587 230605 stage 4.doc Version 1.30 Page 17 Two staff members spoken with indicated that the home appear to be adhering to safe work practices for example the practice of safe moving and handling techniques, which was seen during the inspection. Quality control questionnaires are given to residents and their representatives for example relatives, so that the quality of care can be monitored. Two questionnaires seen completed by relatives had positive responses concerning the quality of care given in the home. The Poplars Residential Home v233587 c51 c01 s55876 the poplars residential home v233587 230605 stage 4.doc Version 1.30 Page 18 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 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x 3 3 The Poplars Residential Home v233587 c51 c01 s55876 the poplars residential home v233587 230605 stage 4.doc Version 1.30 Page 19 No 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 7 Regulation 13(5) Timescale for action The registered person shall make 30/06/05 suitable arrangements to provide a safe system for moving and handling service users. In this instance the care plan must specify the behaviour associated with the resident and the risks involved and clearly notify staff members so that appropriate safety measures can be taken. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 7 Good Practice Recommendations The registered person should involve residents or their relatives in the care planning process and obtain their signatures where possible. The Poplars Residential Home v233587 c51 c01 s55876 the poplars residential home v233587 230605 stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection The Pavilions 5 Smith Way, Grove park Enderby, Leicestershire LE19 1SX 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 Residential Home v233587 c51 c01 s55876 the poplars residential home v233587 230605 stage 4.doc Version 1.30 Page 21 - 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!