CARE HOMES FOR OLDER PEOPLE
The Poplars Residential Home Watling Street Mountsorrel Loughborough LE12 7BD Lead Inspector
Judith Avill Unannounced Inspection 5th December 2006 11:30 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.V320660.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.V320660.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 Mrs Julie Ridding Care Home 21 Category(ies) of Dementia - over 65 years of age (4), 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 (21) The Poplars Residential Home DS0000055876.V320660.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Condition of Registration: No person 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. 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 12 December 2005. 4th October 2005 2. Date of last inspection 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 en-suite facilities. There are two double bedrooms with en-suite facilities. A garden is situated to the rear of the premises. At the time of the inspection the provider had made application to the Commission to transfer a lounge to a double bedroom. The provider reported that fees are in line with Social Service fees and charges are made for hairdressing and chiropody. The Poplars Residential Home DS0000055876.V320660.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This key inspection was undertaken using all of the information available to the inspector regarding service history, surveys completed by residents and returned to the Commission and a visit to the home. The visit to the home took place over 5 hours. The main method of the inspection used was called ‘case tracking’ which involved selecting four residents and tracking the support they receive through the checking of records, discussion with residents, the care staff, the manager and observation of practices. A tour of some of the premises was undertaken with the registered manager and the provider. Documents connected with the running of the home were also inspected. Eleven surveys were received from residents and seven contained positive feedback. The registered provider had completed a pre inspection questionnaire. This provided information about the services provided. Relatives and friends visiting the home were spoken with as part of the inspection process What the service does well: What has improved since the last inspection?
The Poplars Residential Home DS0000055876.V320660.R01.S.doc Version 5.2 Page 6 Relatives commented that the staff at the home kept them well informed about their relatives and the range of activities at the home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Poplars Residential Home DS0000055876.V320660.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection The Poplars Residential Home DS0000055876.V320660.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are good procedures for introducing residents to the home and an assessment is conducted to ensure residents’ needs are met. EVIDENCE: Three resident’s records were seen and indicated that a contract of residence is provided outlining the terms and conditions of residence in the home. Information from surveys from residents and relatives spoken with during the inspection indicated that residents have opportunity to visit the home prior to admission. Resident’s records seen confirmed residents are assessed before being admitted. Relatives said they were aware of care plans. Staff spoken with demonstrated knowledge of residents needs and confirmed that they had access to information before new residents are admitted. Intermediate care is not provided in the home. The Poplars Residential Home DS0000055876.V320660.R01.S.doc Version 5.2 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. 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 do not indicate all the health and welfare needs of residents, which may put residents at risk. Residents are treated with respect. Medication procedures and practices do not protect residents. EVIDENCE: Four care plans were examined. The documents seen included a tick list for the areas of care required. Two records of residents with medical conditions requiring assistance with transfers and mobility stated ‘assist’ and ‘prompt’ but contained no detail of specific action to be taken by staff. Staffs spoken with were well aware of the residents needs. Conversation with one resident and records seen confirmed that residents are involved in the care plan process. Records seen indicated the care plans are reviewed monthly. One resident said that staff were helpful, surveys stated residents were ‘satisfied with the care’, and ‘staff’s interpret my wishes’ and’ no complaints’. From discussion with relatives they said they were satisfied with the care provided at the home.
The Poplars Residential Home DS0000055876.V320660.R01.S.doc Version 5.2 Page 10 Record’s of risk assessments, visits by district nurses general practitioners and other professionals to residents were well documented. The medication process and records were inspected. At the commencement of the inspection the inspector observed unused medication for return to the pharmacist was not secure. The manager secured the medication during the inspection. Medication records were checked and it was identified that one prescribed medication had not been signed for. The staff spoken with were clear on the process of administration. The procedure for staff to follow was seen however this document did not indicate the process for obtaining prescriptions recording, storage of medicines, handling, administration and disposal of medication as described by the manager to the inspector. Staff were observed interacting with residents and one resident spoken with commented that the staff treat them with respect. Information from relatives’ surveys indicated that staff always have a pleasant attitude towards residents. The Poplars Residential Home DS0000055876.V320660.R01.S.doc Version 5.2 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. 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. The management of the resident’s lifestyle includes recreational activities for residents and choices over daily lifestyle. EVIDENCE: Conversations with three residents during the inspection indicated that residents are satisfied with the range of activities at the home. Residents spoken with said they encouraged by staff to maintain contact with relatives and friends. Relatives spoken with commented they were welcome at any reasonable time and were invited to entertainment in the home. The three care plans seen included records of interests and involvement in activities. The fourth record stated the resident’s choice of limited involvement in events in the home. The food seen appeared nutritious and the menu varied. The residents spoken with commented the food was good. Staff were observed by the inspector and were seen to offer choices to residents at the midday meal. The Poplars Residential Home DS0000055876.V320660.R01.S.doc Version 5.2 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. 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. Residents have confidence in staff that their complaints will be taken seriously, and feel safe living at the home. EVIDENCE: Conversations with two residents and three records seen indicate that residents rights are protected. Residents said they could discuss concerns with staff and the manager. The manager reported advocates would be available as required for residents. The two staff spoken with demonstrated a good understanding of adult protection and how they would respond to an allegation or suspicion of abuse if it occurred. The Poplars Residential Home DS0000055876.V320660.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 &26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of cleanliness in some areas of the home was not adequate. Adequate communal space and facilities are provided. EVIDENCE: Walking around the building the inspector observed some carpets in the corridors of the home were marked and there were cobwebs in some of the bathrooms. Other areas of the home seen on the day of inspection were clean and well maintained. The provider reported that domestic staff were not available every day. Residents and relatives spoken with stated they were satisfied with the standard of cleanliness in the home.
The Poplars Residential Home DS0000055876.V320660.R01.S.doc Version 5.2 Page 14 One resident spoken with said they had brought personal possessions and they liked their room. The resident’s rooms seen were clean and had sufficient lighting, heating and ventilation. The provider stated that they had replaced some carpets since the last inspection. The Poplars Residential Home DS0000055876.V320660.R01.S.doc Version 5.2 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 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 adequate. This judgement has been made using available evidence including a visit to this service. The staffing levels do not ensure the standard of hygiene in all areas of the home. Recruitment procedures and staff training safeguard residents. EVIDENCE: The rota provided on the day of inspection indicated that the domestic hours for the home on the week of inspection were 15 hours. The provider reported that the domestic staffing was to be increased. The staff spoken with and records seen indicated that night staff complete some domestic duties during the night. The registered manager works three care shifts as a member of the care team and two days as office duty. The home has a deputy manager who works alternate shifts to the manager. Three staff records were inspected. All files viewed contained two references and satisfactory Criminal Record Bureau checks. Training records were seen and included records on mandatory training, such as moving and handling, first aid and basic food hygiene.
The Poplars Residential Home DS0000055876.V320660.R01.S.doc Version 5.2 Page 16 Training records were maintained and up to date. The staff spoken with confirmed that they had attended mandatory training. One staff reported they had attended training on dementia; another member of staff said they were waiting to attend. Both staff spoken with demonstrated a good knowledge of caring for residents with varying degrees of dementia. The Poplars Residential Home DS0000055876.V320660.R01.S.doc Version 5.2 Page 17 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): 31,33,35,37 &38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is adequately managed. Staff are supervised and health and safety of residents and staff are protected. EVIDENCE: The manager reported she is considering undertaking the Registered Manager’s Award National, a Vocational Qualification (NVQ) level 4. Completing this course would demonstrate that the manager had current knowledge and the skills to manage the home. The management team at the home is responsible for all aspects of care of the residents and the day-to-day running of the home and supervision of staff. The provider is responsible for staff rotas and all area of finance policies and
The Poplars Residential Home DS0000055876.V320660.R01.S.doc Version 5.2 Page 18 procedures. As stated previously in the report the medication policy and procedure needs to reflect action to be taken by staff. On the day of inspection the provider showed the inspector questionnaires returned from residents before the last inspection by the Commission. The comments made in these questionnaires were positive. One resident’s finance record was checked during the inspection. The record was accurate and well maintained. The health and safety documentation that was seen was up to date. The Poplars Residential Home DS0000055876.V320660.R01.S.doc Version 5.2 Page 19 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 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 2 3 The Poplars Residential Home DS0000055876.V320660.R01.S.doc Version 5.2 Page 20 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 OP7 Regulation 15 (1) Requirement The registered person must ensure that care plans include details of ‘how’ the residents needs in respect of his health and welfare are to be met The registered person must further develop the medication procedure to include receipt, recording handling safe keeping, safe administration and disposal of medication The registered person must ensure that all medication administered is signed for The registered person must ensure that at all times there are sufficient domestic staff to ensure that the home is maintained in a clean and hygienic state and free from dirt The registered person must ensure that staff working at the home have specialist training to meet the needs of the residents Timescale for action 27/02/07 2 OP9 13 (2) 27/02/07 3 4 OP9 OP27 13 (2) 18 (1) (a) 27/02/07 27/02/07 5 OP30 18 (1) (i) 27/02/07 The Poplars Residential Home DS0000055876.V320660.R01.S.doc Version 5.2 Page 21 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 OP9 OP27 Good Practice Recommendations Consider the provision of a room for the storage of medication Review the registered managers hours to ensure the administrative tasks, duties and staff supervision are completed The Poplars Residential Home DS0000055876.V320660.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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
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