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Inspection on 24/10/07 for The Poplars Residential Home

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

This inspection was carried out on 24th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

What the care home does well

What has improved since the last inspection?

Care Plans generally indicate how residents needs are to be met. Medication records checked were signed and up to date, which showed that records of medication administered are completed following administration to the resident. There is a detailed medication policy and procedure. There are now cleaning staff on duty five days a week. During the tour of the building all areas of the home appeared clean. Training on dementia is seen as a core training topic so it is expected that staff will attend this training to better understand the needs of residents with dementia.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE The Poplars Residential Home Watling Street Mountsorrel Loughborough LE12 7BD Lead Inspector Keith Charlton Unannounced Inspection 24th October 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Poplars Residential Home DS0000055876.V347858.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 Residential Home DS0000055876.V347858.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Poplars Residential Home Address Watling Street Mountsorrel Loughborough LE12 7BD 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) 0116 2302102 0116 2304485 Mrs Sayida Mawani Mr Riaz Mawani - Vacant Care Home 21 Category(ies) of Dementia - over 65 years of age (6), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (4), Old age, not falling within any other category (23) The Poplars Residential Home DS0000055876.V347858.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Poplars Residential Home is registered to provide personal care for residents falling within the following categories: Older people (OP) 23. Dementia over 65 (DE(E)) 6 Mental disorder excluding learning disability and dementia over 65 (MD(E)) 4 The maximum number of residents that may be accommodated at any on time shall not exceed 23 No Person falling within the category MD(E) may be admitted to the Poplars Residential Home when 4 persons in total this category are already accommodated within the home. No Person falling within the category MD(E) or DE(E) may be admitted to the Poplars Residential Home when 6 persons in total of these categories/combined categories are already accommodated within the home. Variation V27798. The home is able to admit the person, who is under the age of 65 years, named specifically in the variation application number V27798 dated Monday 12th December 2005. 5th December 2006 2. 3. 4. 5. Date of last inspection Brief Description of the Service: The Poplars care home cares for twenty three older persons, some of which have dementia or mental health needs in a large 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 en-suite facilities. There are three double bedrooms. There is a large garden to the front and a garden patio situated to the rear of the premises. The weekly fees are from £335 to £375 – this information was provided on the day of the inspection. There are additional costs for individual expenditure such as hairdressing, toiletries, etc. A Statement of Purpose and Service Users Guide to the services the home offers can be supplied to applicants and the last Inspection Report is available in the hallway, to enable prospective residents to make an informed choice as to whether they wish to live at the home. The Poplars Residential Home DS0000055876.V347858.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided… The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. This was an unannounced Inspection. The Acting Manager and Registered Provider were on duty. Planning for the Inspection included reading the notifications of significant events sent to the Commission for Social Care Inspection and the last Inspection Report, plus the Annual Quality Assurance Assessment, which provides information as to the services the home provides. The Inspection took place between 09.30 and 16.00. The inspection included a tour of the building, inspection of records and indirect observation of care practices. The Inspector spoke with eight residents, three members of staff, two visitors, the Acting Manager and Registered Provider. There were six surveys sent to the Commission for Social Care Inspection from relatives – all were complimentary regarding the care that staff supplied to residents, and there were a number of very complimentary comments: There is a ‘’cheerful, homely and caring atmosphere’’. My relative ‘’is content and happy at the Poplars’’. ‘’I would like to say thank you to the management and the staff for taking care of (my relative). They do their best to make (her) life as pleasant as possible’’. What the service does well: There were a range of issues which covered residents needs – residents spoken to were very satisfied with the care they received from staff, they thought that the food was good, that there are a range of activities provided and that the home in general and their bedrooms were kept clean and tidy. The inspector also observed that staff were friendly and helpful in their dealings with residents. Residents said visitors are made welcome, which was confirmed by two visitors, and residents feel that the management would quickly act on any issue they raise. The Poplars Residential Home DS0000055876.V347858.R01.S.doc Version 5.2 Page 6 Residents needs are actively promoted. Staff were aware of how to promote residents independence and this was reflected in residents Care Plans. The Acting Manager has set up a system of staff having access to a summary of residents Care Plans. Regular activities are provided and residents asked in Residents Meetings as to their preferred activities. Residents said that they were generally free to do what they wanted. The home was found to be clean and tidy and odour free. Bedrooms were homely and personalised with residents stating they were happy with them and they could bring in their personal possessions. Staff training is encouraged so that staff carry out most essential training and they are encouraged to undertake National Vocational Qualification training to add to their care skills. Staff are asked to read the Policies and Procedures of the home so that they know what to do and are consistent in their work. What has improved since the last inspection? What they could do better: Residents needs would be more effectively covered by ensuring that: Staff are asked to read residents full Care Plans so that they know what to do and are consistent in their work. Assessments contain evidence of the last appointments with Medical Services – dentist, optician etc, that Care Plans contain more specific detail as to The Poplars Residential Home DS0000055876.V347858.R01.S.doc Version 5.2 Page 7 residents continence needs so that staff can offer the toilet before residents need to go, that it indicates choice in residents daily lives – for example that residents can go out unaided or with staff if they choose and if keep alcohol in their room if this does not present a problem; that there is a medication storeroom for the storage and management of medication to enable staff to store all medication in one place use the room for checking medication and ordering of medication and improve access for residents and staff. Staff must always ensure that residents privacy is respected by shutting doors to toilets when they are assisting residents. Staffing levels need to be increased to ensure that there are sufficient staff to cover residents needs at all times, to extend the training programme to include some more relevant issues regarding residents care so that staff to have knowledge of residents conditions, e.g. stroke management, diabetes, hearing and sight impairment etc. Health and safety systems need to be tightened to ensure that fire doors are kept closed unless on approved fire closures, that access to Control of Substances Hazardous to Health is restricted by ensuring storerooms and cupboards are secure, and that paving stones to the front of the home are not broken and are flat to the ground so residents do not trip on them. It is recommended that residents are encouraged to have a greater say in the running of the home in that a representative from the resident group can sit on staff recruitment interviews and in staff meetings. There needs to be a Registered Manager in place in the near future. 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 Residential Home DS0000055876.V347858.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 Residential Home DS0000055876.V347858.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): 3,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process meets the needs of residents. EVIDENCE: Some residents said that management visited them before their admission into the home and talked about their care needs. They had the option of visiting the home prior to their admission. The Inspector looked at residents files, which contained relevant information in terms of medical, physical and social needs of residents. The Poplars Residential Home DS0000055876.V347858.R01.S.doc Version 5.2 Page 10 The Acting Manager was asked to ensure that the form includes medical checks – last optical and dental checks, whether there is a need to refer to medical services regarding hearing tests etc. The Registered Provider does not provide intermediate care. The Poplars Residential Home DS0000055876.V347858.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans identify most care needs and generally outline action to ensure residents needs are met. Residents health needs are monitored but always need to be acted upon. Residents privacy is not always upheld. There is an effective medication system in place. EVIDENCE: No residents said that they were aware of Care Plans. It is recommended that residents or relatives (with residents permission) are reminded that they can see Plans and ask for changes if they do not feel they are accurate. Care plans inspected were found to contain relevant information regarding residents needs. There are also Risk Assessments so as to manage any area of risk to residents. The Poplars Residential Home DS0000055876.V347858.R01.S.doc Version 5.2 Page 12 Some areas of need are not specific enough – e.g. there was no evidence of when appointments are needed regarding when checks are needed, e.g. for the optician and dentist, the need for a hearing test etc though there was good information regarding residents appointments with medical services – the GP, District Nurse etc. There was a discussion with the Registered Manager regarding Care Plans being more specific as to the frequency residents with continence difficulties needing to be taken to the toilet based on their assessed needs. The Acting Manager said that she would update the plans. Care records were kept on a daily basis and were detailed as to residents care needs. It is recommended that there is a personal history section in Care Plans to ensure residents are seen as individuals with a valued past. Staff said they had not read all the Care Plans, which is needed to help to ensure that all relevant information is available for staff to meet residents needs. The Acting Manager said she would ask staff to read all the Plans and to sign to this effect. She had set up a system of having a summary of the plans available for staff, which is commended. Monthly reviews of plans had been carried out to ensure they were still relevant to residents needs. Records show that medical services are contacted following illness to a resident and residents and a relative spoken with confirmed this. Accident records were viewed and it was found that incidents had largely been properly followed up with medical services where necessary, though there were some instances where this was not the case, e.g. on 17/10/07 when there was a head injury. The Acting Manager said she would remind staff to do this. It is recommended that a short procedure is set up for staff as to when to alert medical services. Medication records were found to be up to date, with no gaps on records. Staff members said they only senior staff administer medication. The Acting Manager showed the inspector a checklist that she went through with senior staff to ensure they understood the proper procedure and that there is also training from the pharmacist, which she showed the inspector evidence of. Medication is kept in locked and properly secured trolleys though having a medication room is still recommended to improve access in the area where the trolleys are and to lessen any distractions on staff issuing medication. There is a record for the recording of controlled drugs. The Acting Manager needs to check with the pharmacist whether this constitutes a proper register under the terms of the legislation. Proper returns records for medication were seen to be in place. The Poplars Residential Home DS0000055876.V347858.R01.S.doc Version 5.2 Page 13 Staff were observed to be talking to the residents with respect and friendliness. Residents said that staff were ‘really friendly’ respected their privacy and dignity. The visiting relative also said staff were welcoming and friendly. Another visitor said that he had the highest praise for staff providing excellent support to his friend when she was in the last stages of life. This situation is highly commended. There was one instance where the inspector observed a staff member assisting a resident in the toilet with the door partly open. The Acting Manager said this would be followed up as it was against the ethos of the home. The Poplars Residential Home DS0000055876.V347858.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 good. This judgement has been made using available evidence including a visit to this service. Residents have opportunities to have a stimulating lifestyle, though this needs to be extended. EVIDENCE: Residents said that they were generally satisfied with the range of activities on offer and they liked it when staff had time to sit and chat with them, which was not too often as staff were so busy. They said they would like more walks out with staff and more entertainment coming in. There is a full time Activities Organiser employed and weekly Activities Programme and residents meeting notes also recorded choices put forward regarding activities. There is also a record as to the activities residents have participated in. It was recommended that staff receive training on providing activities for residents with dementia. The Poplars Residential Home DS0000055876.V347858.R01.S.doc Version 5.2 Page 15 Residents Meetings have been organised though because a number of residents have dementia and some it difficult to communicate the inspector recommended that joint residents/relatives meetings be set up to inform management as to suggestions/quality of life issues for residents. The Acting Manager said this would be followed up. It was also recommended that memory boxes, containing valued items, be set up for residents, so as to provide valuable reminiscence material for residents with dementia. Residents said they liked going outside but there were a number of comments that they were confined to going out to the back patio area and could not use the large front garden, and that they would like more outings. The Acting Manager and Registered Provider said it was not the case that residents were confined and residents were taken for walks. It is recommended that residents preferences in this regard be recorded in their individual Care Plans – how often they would like to go for walks etc. The Acting Manager said residents have the opportunity to go on outings and this was confirmed in minutes of the residents meetings. Residents and the relative spoken to said that visitors were made welcome by staff. Residents again said that they thought there were no rules and they could please themselves about things – getting up and going to bed times, when to have a bath, etc and that staff encouraged them to retain their independence. Some residents said that they were not sure they could keep alcohol in their bedrooms. The inspector asked the Acting Manager to look into this so that residents could have choice in this matter if there were no identified issues in Risk Assessments. Staff said that it was important that residents were able to do things for themselves, and confirmed that encouraging independence was the aim of the service. Residents said they thought the food was generally good and there were choices for meals. Food records were generally detailed though did not record the variety of vegetables offered and were not dated. The Acting Manager said this would be followed up. The food tasted was found to be of a satisfactory standard with two courses and choices of the main meal with two vegetables plus potatoes served. The Acting Manager said it was important that residents were supplied with fruit and vegetables so that a healthy diet is available. A soft diet was available to residents who needed this and staff were seen to be assisting residents to eat. It was also recommended that a menu board be displayed to supply information to residents. The Poplars Residential Home DS0000055876.V347858.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 current system generally protects residents from the possibility of abuse though staff awareness of the full procedure needs to be increased. EVIDENCE: Residents said that they did not need to complain but if they did they thought the management would look into it properly if they ever needed to. The Complaints file was viewed where there was no evidence of any complaints made directly to the home. One complaint came to the Commission for Social Care Inspection, which was passed on to the Registered Provider who provided detail of evidence that did not support the complaint. However the Complaints Procedure needs to be altered to give the complainant the choice at the initial stage to go to the investigating body – the local Social Service Department - now the lead agency for investigating complaints – as well as the home. The Registered Provider said this would be changed. The Poplars Residential Home DS0000055876.V347858.R01.S.doc Version 5.2 Page 17 Staff members were asked about their understanding of the adult protection procedures, and demonstrated a generally good understanding of these though they struggled on knowing all outside agencies to contact. The Acting Manager said that staff had attended Protection of Vulnerable Adults training held by the home but this would be further followed up to ensure greater knowledge. There is a Residents Meeting held where all residents are invited to attend and share their views about the home. The Acting Manager keeps good detailed records of the Meetings. The Poplars Residential Home DS0000055876.V347858.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): 19,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A homely, generally clean and attractive environment is provided to residents. EVIDENCE: Residents all said that they liked the home’s facilities and that it was kept clean and tidy with no odours. They said they could have their bedrooms in the way they wanted and could bring in their own furniture and other personal possessions. Bedrooms were observed to be personalised and homely by the inspector. The Poplars Residential Home DS0000055876.V347858.R01.S.doc Version 5.2 Page 19 Facilities were found to be clean and odour free. There was one bedroom with an ingrained stain. The Registered Provider said this carpet would be replaced in the near future. There was another bedroom with glass to a wall section and above the door, which could disturb that resident’s sleep. The Acting Manager said this would be checked. A WC next door to the office needed repair. Residents praised the domestic worker, and said that the laundry service was good; their clothes did not get lost and were always freshly laundered. There are single bedrooms for most residents. Facilities are generally well decorated. There was a discussion with the Acting Manager as to signing the environment for residents with dementia – e.g. colour coding doors to bathrooms, pictures on bedroom doors etc. The Acting Manager said this would be followed up. As there is a noise nuisance between one lounge and another it was recommended that doors be fitted between then to lessen this. Installing net windows to front bedrooms would increase residents privacy. The Acting Manager was asked to look at alternative storing of cardboard boxes in residents bedrooms so that this increased the homely feel of the bedrooms. There is a maintenance person who can attend to issues that arise. The Poplars Residential Home DS0000055876.V347858.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. Staffing levels may not meet residents needs. Recruitment processes are generally thorough to ensure the protection of residents from unsuitable staff. A staff training system is in place to ensure staff are aware of residents needs though this needs to be extended. EVIDENCE: Residents said that they usually did not have to wait too long if they needed help though there was sometimes a problem with staff shortages. One resident said there was a long wait to have the call bell answered on occasion. There is a staffing ratio of three care staff on each floor all day/evening with awake night staff members on duty at night. The Acting Manager said she works on the floor in the afternoon, though this will be limited on occasion with management duties as they arise. The Poplars Residential Home DS0000055876.V347858.R01.S.doc Version 5.2 Page 21 There were other comments received by the inspector that staffing levels were not always sufficient and other information, which supported this position in the Quality Assurance Survey of 2007. From the records inspected there is a high level of dependency needs – according to the Acting Manager and Registered Provider most of the residents have dementia or confusion, a number of residents need two staff to one resident for personal care/and there was one resident who needs care in her bedroom due to long term illness. With this level of need there would appear to be a need to increase staffing ratios to having four care staff as a minimum for the busy morning period and to ensure residents have their care needs fully met and are available to take residents out for walks or for other activities – chatting with them etc. Staff records were inspected and generally met expected standards with two references and Criminal Records Bureau checks obtained, copies of passport or similar ID. One file did not appear to have a reference from the last employer though the Registered Provider said this was due to there not being a updated Application form and that this would be followed up. Staff said that training is provided and that there is encouragement to complete National Vocational Qualification training. There were training certificates on file to validate training. There is a core training programme for staff – e.g. for Health and Safety, Protection of Vulnerable Adults, First Aid, Dementia, Medication etc though not all staff had received this training. As discussed with the Acting Manager and Registered Provider there is a need to extend core training topics to add other essential topics and adding knowledge of residents conditions, e.g. challenging behaviour, health and safety, fire, infection control, stroke management, diabetes, parkinsons disease, hearing and sight impairment etc, to the list of training issues. There is an induction programme, which covers relevant topics. The Registered Provider said that the recognised Skills for Care induction booklet would be used in the future. The Registered Manager keeps a training matrix for staff to quickly identify training needs of individual staff, which is a useful tool. The Poplars Residential Home DS0000055876.V347858.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): 31,33,35,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are not fully in place to protect the health and safety of residents. EVIDENCE: From information received from residents, visitors and staff there was a consistent message that the Acting Manager and Registered Provider upheld residents welfare. The Acting Manager is a Registered Nurse. The Poplars Residential Home DS0000055876.V347858.R01.S.doc Version 5.2 Page 23 There was information that staff receive supervision on a regular basis. It was recommended that this include an assessment from management regarding individual training needs. Residents monies records are clear so that there is a record for each transaction and that two staff, or one staff plus a resident/ representative sign each transaction. Some monies were checked and found to be correct. There was evidence that ongoing Quality Assurance surveys are carried out with residents and relatives, that this information is analysed and information is included in the Statement of Purpose. Staff meetings are held frequently with good records of relevant issues discussed. The inspector noted concerns as to some issues – a store cupboard with Control of Substances Hazardous to Health products in it was left unlocked despite a notice stating it needed to be kept locked, there was an unlocked cupboard in a bathroom near lounges with scissors accessible to anyone in them and the kitchen door was found to be wedged open at various times of the day (the Acting Manager finally confiscated this wedge so that it could not be used to compromise fire safety). Some of the paving stones to the front of the home were found to be broken or not properly bedded down therefore causing a tripping hazard. The Acting Manager said vehicles had caused this damage and it would be repaired. There are Risk Assessments for safe working practices that have been carried out for issues that present risk for issues that may present a danger to residents and staff. A Risk Assessment was needed for the stairs near the offices on the first floor, as there was no guardrail to stop residents from falling. The Acting Manager said this would be carried out and a rail fitted if needed. Fire Precautions: fire drills had been not always been carried out at three monthly intervals as there was a six month gap between 2006 and 2007. Staff spoken to by the inspector were mostly aware of the proper fire procedure though one staff member was unsure regarding contacting the fire service. The Acting Manager said these issues would be followed up. There was a fire risk assessment for the home, to ensure that fire issues have been considered and residents protected from fire. The Registered Provider agreed to revise this in line with more detailed fire service guidance. Emergency lighting testing was being carried out on the required monthly basis and fire bell testing was mostly carried out on the required weekly basis though for some entries this was over a week between tests. The Registered Provider said that the Requirement from the Fire Officer in 2005 with regard to ensuring proper fire protection for fire doors had been met The Poplars Residential Home DS0000055876.V347858.R01.S.doc Version 5.2 Page 24 by the required work being carried out, though there was no supporting evidence to state this. A hot water outlet in a first floor bathroom was found to be 34c, which met the National Minimum Standard of 43c, to prevent a scalding risk to residents. However this was lukewarm and would not provide a cosy bath temperature for residents and it took some time for warm water to come through. The Registered Provider is to book a plumber to have this looked at. There are radiator covers to protect residents from burning. The Poplars Residential Home DS0000055876.V347858.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 3 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 The Poplars Residential Home DS0000055876.V347858.R01.S.doc Version 5.2 Page 26 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 OP8 Regulation 12 Requirement There must always be referral to Medical Services if residents receive potentially serious injuries. Residents privacy must be respected at all times. Timescale for action 24/10/07 2. 3. OP10 OP27 12 18 24/10/07 The registered person must 24/12/07 ensure that at all times there are sufficient care and domestic staff to ensure that residents needs are fully covered and that the home is always maintained in a clean and hygienic state, so higher staffing levels are needed. The Registered Provider must ensure that all health and safety systems are in place to protect residents - e.g. fire systems meet Requirements and storage covering Control of Substances Hazardous to Health and dangerous items are kept secure. 24/10/07 4. OP38 23 The Poplars Residential Home DS0000055876.V347858.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. Refer to Standard OP7 OP12 Good Practice Recommendations The registered person must ensure that care plans include all details in respect of health and welfare needs. It is recommended that a staff member, e.g. Activities Organiser, attend a specialised training course to provide appropriate activities for residents with dementia and that there is a full signing system in the environment to assist residents. Activities need to be reviewed as regards residents wishing to have more walks and trips out and this be recorded in residents Care Plans. The staff training programme needs to be extended to cover all relevant topics regarding residents care. 3. OP30 The Poplars Residential Home DS0000055876.V347858.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Residential Home DS0000055876.V347858.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. 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