Care Home: Poplars

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What the care home does well The admission processes in the home were managed well, with visits and interviews arranged prior to a new resident moving in. A detailed initial admission assessment gives a good base line for the installation of good care planning. Both residents and relatives alike were complimentary regarding the management and staff within the home. A resident commented that the `carers are lovely` and a relative said that `staff are good`. The manager was said to be both approachable and professional and the housekeepers were praised for keeping the home clean and tidy. In addition, catering staff were also praised with a resident saying that the `Cook is brilliant`. What has improved since the last inspection? There were no requirements and recommendations following this inspection.There has been some improvement in the care planning and risk assessment paperwork since the last inspection and record keeping relating to complaints has improved. Ongoing maintenance and decoration continues in the home. Evidence was seen of completed decoration and further decoration is planned throughout the home covering bedroom accommodation and communal areas including bathrooms and toilets in the home. Staffing levels and staff working long hours has improved since the last inspection. More staff are employed at the home and this means that staff are not expected to work excessive long hours to cover shifts. This was evidenced in the staff rota and from speaking to management and staff. What the care home could do better: There is still room for improvement in the amount of information found in both care plans and risk assessments. Whilst there was evidence of sufficient information given to enable staff to care for residents, there were also examples of where this information had been lacking in detail and did not give sufficient detail. The manager acknowledged that there were shortfalls and a review of care planning and risk assessments were to be carried out. CARE HOMES FOR OLDER PEOPLE Poplars 63 Naze Park Road Walton On Naze Essex CO14 8LA Lead Inspector Pauline Dean Unannounced Inspection 09:45 11 February 2009 th 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 Poplars DS0000017911.V371409.R04.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. Poplars DS0000017911.V371409.R04.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Poplars Address 63 Naze Park Road Walton On Naze Essex CO14 8LA 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) 01255 675557 01255 676466 Southend Care Limited Victor Zingoni Care Home 37 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (37) of places Poplars DS0000017911.V371409.R04.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Persons of either sex, aged 65 years and over, who only fall within the category of old age (not to exceed 37 persons) The room registered on 30 May 2003 must not be used by a service user who uses a wheelchair Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 16 persons) The total number of service users accommodated must not exceed 37 persons The registered provider must review staffing levels (care and ancillary) in consultation with the Commission, within six months of dementia registration, to ensure that staffing levels are sufficient to meet the needs and number of service users 25th September 2007 Date of last inspection Brief Description of the Service: Poplars is a detached, two story property in Walton on the Naze, Essex, in an attractive location with views over the sea. The home is registered for 37 residents. Bedroom accommodation comprises of 3 double rooms and 31 single rooms, 15 with en-suite toilets. The home is registered for 16 residents with dementia. There are two large lounge/dining rooms and a small lounge/dining area on the ground floor with a smaller lounge on the first floor. The home provides 24-hour personal care and support, and has a through-floor lift and other equipment (e.g. mobile hoist, hand rails, etc.) to assist residents with limited mobility. The registered provider is Southend Care, and the registered manager is Victor Zingoni. On the day of the site visit the charges per week are as follows: £383.00 - £420.00. Hairdressing, chiropody, outings, newspapers, toiletries and manicures are additional costs and are charged at cost. Poplars DS0000017911.V371409.R04.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This unannounced inspection of Poplars took place on 11th February 2009 over a 9½-hour period. The inspection involved checking information received by Commission for Social Care Inspection (CSCI) since the last key inspection in September 2007. At the inspection, records and documents were inspected and we spoke to the registered manager, care staff, visitors, relatives and the people living at the home. In addition the Annual Quality Assurance Assessment (AQAA) completed in May 2008 was considered as part of the inspection process and a tour of the premises was completed. Surveys were sent to the home prior to the inspection. Three surveys were completed and returned to the Commission, one by a resident living at the home, one from a member of the care staff and one from a health professional. Their comments are reflected in this report. During the inspection three people who live at the care home, two carers and two visitors were spoken with. What the service does well: What has improved since the last inspection? There were no requirements and recommendations following this inspection. Poplars DS0000017911.V371409.R04.S.doc Version 5.2 Page 6 There has been some improvement in the care planning and risk assessment paperwork since the last inspection and record keeping relating to complaints has improved. Ongoing maintenance and decoration continues in the home. Evidence was seen of completed decoration and further decoration is planned throughout the home covering bedroom accommodation and communal areas including bathrooms and toilets in the home. Staffing levels and staff working long hours has improved since the last inspection. More staff are employed at the home and this means that staff are not expected to work excessive long hours to cover shifts. This was evidenced in the staff rota and from speaking to management and staff. 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. Poplars DS0000017911.V371409.R04.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 Poplars DS0000017911.V371409.R04.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 & 6. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who come to live at the home can be confident that their needs will be fully assessed and these will be met. EVIDENCE: On the 11th February 2009 there were thirty-four people living at Poplars Care Home. At this inspection, the files and paperwork for three people living at the care home were sampled and inspected and we were able to speak to two of these residents and a third resident. Poplars DS0000017911.V371409.R04.S.doc Version 5.2 Page 9 The pre-admission paperwork for two people who had moved into the home since the last inspection was also sampled and inspected. One person had moved into the home in August 2008 and the second person had moved into the home initially for three week’s respite care in January 2009. Detailed pre-admission assessments had been completed based on the ‘Activities of Daily Living’ format. The manager told us that a placement coordinator normally undertakes this role and examples of pre-care assessments were seen on the files of the two new residents. The AQAA said that ‘Before each resident is admitted to the home, they have to have a pre-admission assessment carried out by our placement co-ordinator. The purpose of this is to find out if the home could be able to meet their needs and other relevant information that would benefit the Home in caring for them. Those being admitted on a private basis would undergo the same process of admission.’ The completed assessment covered issues such as mobility, personal safety, food intake, elimination and the individual’s routines of daily living and their likes and dislikes. Information was also gathered as to the person’s cultural/religious and spiritual needs and their welfare and finances and any safeguarding concerns. In addition detailed records were made of the person’s medical history and physical condition and a memory tool/questionnaire was completed on admission. The AQAA stated that following ‘the initial assessment, the care plan would be generated to meet the resident’s care needs, including medical, risk assessment, falls prevention, food intake, personal safety and various other care needs.’ This was as found on the files sampled. The manager said that prospective residents are encouraged to visit the home with their family before they make a decision to stay. This was confirmed in the AQAA in which it was said - ‘Each resident is given the opportunity to view the home prior to their admission so that they can make an informed choice of the home they want to live in’. One survey completed by a resident said that they had received enough information about the home before moving so that they could decide if it was the right place for them. Poplars does not offer intermediate care. Poplars DS0000017911.V371409.R04.S.doc Version 5.2 Page 10 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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home can be assured that their care needs will be met through their individual plan of care and they can be assured that their medication will be administered in a safe and secure way. EVIDENCE: Three care plans were sampled and inspected as part of case tracking of the care offered at the home. The care plan formats seen allowed consideration of all aspects of the health, personal and social care needs of the resident. Care planning files were in good order with each file having a photograph of the Poplars DS0000017911.V371409.R04.S.doc Version 5.2 Page 11 person, health, personal and family history and an inventory completed as the new resident came to live at Poplars. The care plan covered care needs relating to communication, psychological needs, personal care, skin care, mobility, eating and drinking, elimination and the routine of daily living/activities including night care/ rest and sleep etc. This had been created following the pre-admission assessment using the ‘Activities of Daily Living’ format and in the three files sampled we noted that there was a minimum of ten care plan objectives. Within the care plans inspected the detail given varied. We saw good examples where sufficient information was given for care staff to follow to ensure that they were enabling the person to maintain their own independence. This was in the management of their personal care tasks relating to washing and bathing. However, we also saw another example of the management of personal care where it stated - ‘He can do it independently at present.’ These examples were raised with the manager and it was acknowledged that all care plans need to be reviewed to ensure that there is consistency in the care planning and care staff are given sufficient information to perform care duties. A variety of risk assessments were in place ranging from risk assessments around mobility, security, risk of falls and nutrition. As with the care plans the amount of detail given varied. An example seen was with regard to a resident’s risk of falls. Whilst the risk and the harm had been identified and there were detailed options as to how the home would manage this risk, the risk assessment did not detail which option was to be followed. This was raised and discussed with the manager and it was agreed that this would be reviewed immediately. Within the AQAA it was stated ‘… care plans are designed to cover all aspects of their care and needs. This is evidenced by the relevant topics covered in their care plan, (risk assessment, nutritional, pressure sore care, mental health assessment, and various other topics.)’ The manager told us that all of the residents use two local GP surgeries. Both the District Nursing Service and the Community Psychiatric Nurse were said to be readily available and the manager said that they received a good service from them. A survey was completed and returned to the Commission for Social Care Inspection (CSCI) by a healthcare professional. This had positive comments regarding the healthcare arrangements in the home. When asked if the care service sought advice and acted upon it to manage and improve individuals’ health care needs, the response was ‘always’ and to the question ‘Are individuals’ health care needs met by the care service?’ the response was again positive –‘always.’ Poplars DS0000017911.V371409.R04.S.doc Version 5.2 Page 12 Two residents spoken on the inspection said ‘we are very well looked after’. They said that should they feel unwell a GP would be called and their family informed. Another resident told us that following an assessment where a hearing problem had been identified, the home had arranged a hearing test and they now have a hearing aid. Within the AQAA it was said that the home would like ‘ to continue improving our care plans. To try and get all medical history for the resident so we could put a comprehensive care plan centred around their needs.’ Medication administration was sampled and inspected. The Monitored Dosage System (MDS) is used in the home and there is secure storage within a cupboard, medication trolley and two medication fridges. The Medication Administration Record (MAR) sheets were sampled and inspected for the three residents who were part of the case tracking. The administration record keeping was in good order, with records seen of an audit conducted as medication came into the home. This inspection took place at the start of the twenty-eight day period and a senior carer told us the home was chasing some outstanding medication. This was now seen as a matter of urgency for seven days had passed and this medication was required that day. On the day of the inspection four residents were receiving controlled drugs. These were stored in a designated wall safe in the medication cupboard and records were seen of two staff signatures administering and witnessing the medication being given. A list of staff signatures and initials were kept to aid identification of the staff member administering medication. Medications held in the two medication fridges found in the two main lounge areas were stored at an appropriate temperature. Records of temperature checks were seen on this inspection. During this inspection we were able to observe staff as they went about their duties. We were able to see staff speaking to residents in a respectful manner. Carers were seen to close bedroom and bathroom doors as they attended to their personal care needs. One person said the ‘carers are lovely’ and another resident said that the ‘carers were caring’. Two visitors spoken to during the inspection were also very positive regarding care staff. One said that ‘staff are good’ and the other said that they were ‘very pleased with care’ provided. Poplars DS0000017911.V371409.R04.S.doc Version 5.2 Page 13 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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service People who live at the home can expect to be given choices about how they spend their time, visiting arrangements and meals. EVIDENCE: Poplars have a programme of activities for the people living there. This programme was on display in the two main lounges and on the day of the inspection, some residents were seen playing card and board games, others were watching the television, whilst some were having their nails manicured and others were knitting. Three residents told us what they like to do during the day. Each of them told us that they were able to choose whether they wished to join in a group Poplars DS0000017911.V371409.R04.S.doc Version 5.2 Page 14 activity in one of the main lounges or adjourn to a smaller quiet lounge or their bedroom. In the AQAA it was said that ‘At Poplars we endeavour to maintain flexibility in offering choices on how the service users wishes to spend their day. We strive to meet their recreational needs by providing a modest activity programme designed to meet the physical stimulation of the service users. We encourage contact with their families and friends. We have areas for service users to use when they have visitors and we have no rules where the residents spend their day, as long as they are happy and content. We have a computer area where resident and families have access to the internet’. These areas and facilities were seen and visitors confirmed that they were aware of them. One resident told us that they enjoyed playing card and board games in one of the main lounges and they also enjoyed watching sport on their television in their room. They were also pleased to be able to receive visits from their Pastor/Minister. Two residents told us that they were able to go out with their families as they wished. They particularly enjoyed joint outings with their relatives to a local café. Knitting was also popular with some of the residents and a resident told us that in the past residents had made knitted blankets and baby clothes for charity, relatives and staff members. They said that relatives and staff supply the materials. The manager told us and the AQAA confirmed it that the home is looking to ‘creating a robust activities programme to cater for all residents in the home. We could also encourage the residents’ families to get involved in the activities’. They also told us that they are looking towards volunteers coming into the home to help with activities following a recent meeting the manager had attended. This meeting had been entitled ‘Bringing the Community Home’ and in the AQAA it was stated that the home was looking for ideas from branches of local charities such as the Sunshine Project and Help the Aged. Two visitors were spoken to during this inspection. Both told us that they and their families were made very welcome when they visited the home. They said that residents were able to greet them in their room, in one of the smaller quiet lounges or in the main lounge areas. One relative told us that a relative regularly had lunch with a resident each week and both parties appreciated this. A relative said that when they leave the home they ‘always feel happy and they have a smile on their face and they are secure in the knowledge that their relative is well care for’. Evidence was seen on care planning files that residents are able to bring in some personal possessions. Inventories were seen on these files and personal Poplars DS0000017911.V371409.R04.S.doc Version 5.2 Page 15 items such as bedroom furniture, pictures, photographs, books and ornaments were seen in the bedrooms. The majority of the residents also had their own televisions. Three residents spoken to confirmed that they had brought items from their home and this made their room feel more homely. A relative commented that their relative’s room was ‘lovely’. At this inspection we were able to speak with catering staff in the kitchen. Between them they had considerable experience of providing nutritious meals for the residents. The Cook told us that the home operates a four-week rotation menu, with a minimum of two choices offered at each meal. Records were seen of the preferences of residents and special dietary needs are considered. Currently the home is catering for residents with diabetes and soft diets. They told us that they had had to previously cater for a resident who required a Coeliac Diet and they said that they and the seniors had undertaken some research and an information folder had been compiled for reference. This was noted in the AQAA. Records of food eaten are held on the care plan file of each resident and residents are regularly weighed. Two residents spoken to were complimentary regarding the food served. They told us that there are normally two roast dinners each week and when birthdays are celebrated the cook makes a ‘lovely’ cake. They also confirmed that diabetics are considered in the food served and they were able to tell us what meals were planned for that day. One resident said the home served ‘very good food’ and another resident said the ‘Cook is brilliant’. Poplars DS0000017911.V371409.R04.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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home can expect their concerns to be taken seriously by the care home. EVIDENCE: Poplars have a complaints procedure in place. It was detailed and easily understood and stated that all complaints would be responded to within 28 days. The manager said that the home had received one complaint since the last inspection in January 2008. The Commission had been copied into this complaint by the complainant and the home had been advised to follow up the complaint through their complaints procedure. Southend Care’s Operations Manager had completed a complaint’s investigation and a detailed response had been sent to the complainant, Social Services and the Commission for Social Care Inspection (CSCI). Within this report recommendations were made regarding the management of weight loss and pain management. The manager told us that both of these matters had been considered and evidence was seen of the action taken. Poplars DS0000017911.V371409.R04.S.doc Version 5.2 Page 17 The home has copies of the local authority’s adult protection guidelines. The manager told us that the home uses the Essex County Council Safeguarding Adults training materials and Safeguarding Alert forms as provided by the local authority are readily available for completion. In addition Poplars works with the policies produced by the registered provider - Southend Care. These are outlined in the staff handbook for their information. A senior carer spoken to at the inspection confirmed that they were aware of the need to raise concerns should they suspect abuse. They told us that they knew how to do this and they confirmed that they had attended Safeguarding training. A carer who had completed the Commission for Social Care Inspection (CSCI)’s survey also confirmed that they knew what to do should a concern be raised. Two visitors to the home said that if they had concerns they would raise them with the manager who they found approachable. In the AQAA it said that the ‘Complaints procedures are in place and staff and residents are aware of the complaints procedures and how to access it. Any complaint that is raised is investigated and responded to within 28 days by our Operations Manager or an Independent Care Consultant. Complaints are recorded and logged in our complaint folder/book’. It went on to say ‘Families and residents are encouraged to see the manager as much as they can to express their concerns and are also encouraged to write any compliments in our compliments folder by the front door’. Poplars DS0000017911.V371409.R04.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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at Poplars have homely, comfortable and safe surroundings, which are kept clean and tidy. EVIDENCE: A tour of the premises was conducted on this inspection. All communal areas, the laundry, kitchen, bathrooms and some toilets and bedrooms were seen. There were no unpleasant odours or smells and the home was clean. The home is divided into three bedroom accommodation areas called Squirrel, Peacehaven and Seaview. Poplars DS0000017911.V371409.R04.S.doc Version 5.2 Page 19 Since the last inspection, the home had had a visit from the Fire Service. Some action had been required regarding fire doors, heat and smoke seals and emergency lighting. The manager said that an electrician had completed the work, but they were unable to locate the paperwork to confirm this. They said that they would chase this up with the main office. In August 2008, the Environmental Health Officer had visited the home to conduct a Food Hygiene inspection. No action had been required following this visit. The manager told us that there is an ongoing decorating and maintenance programme. As bedrooms become vacant they are decorated and new carpet, curtaining and furniture are purchased. As we were taken around the home we saw some vacant bedrooms, which had been prepared for decoration. Some new radiator covers had also been fitted and they are awaiting painting. Within the AQAA it was stated that ‘As part of our improvements we have redecorated 6 rooms as they became vacant’. It was also said that photographs of residents had been displayed on their bedroom door and this was seen at the inspection. The home said the photographs were there to assist residents with dementia to locate their rooms. All three residents spoken said that they were pleased with their rooms. One resident had recently been offered the chance to move into a larger room and they were pleased that they had been able to take up this opportunity. A relative spoken to at the inspection said that their relative’s bedroom was ‘lovely’. When asked in the AQAA what the home did well with regard to the environment, they had highlighted their gardens. It was said that ‘We have a beautiful garden where residents and their families can sit in and enjoy the view offered by the gardens’. As well as sea views residents are able to sit out in a patio area around a fishpond and flowerbeds. Two residents told us that they enjoy sitting outside in the summer months. A laundry person is employed five days a week. The laundry room is within the home away from the areas where food is stored or prepared. There are two industrial dryers and two industrial washers. The machines have sluicing programmes and we were told that there are four sluices within the home. Residents’ clothing had name labels attached. A relative told us that their relative had experienced some problems with clothes going missing, but when they had raised this with care staff they had found the clothing immediately. Poplars DS0000017911.V371409.R04.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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home can expect to be supported by sufficient staff with skills and knowledge to meet their needs. They can be assured that appropriate recruitment practice has been followed to safeguard their welfare. EVIDENCE: Staffing rotas were inspected and we were able to see that seven carers are on duty in the morning, six carers on the afternoon/evening shift and three carers are on waking night duty. Additional auxiliary staff comprises of six housekeepers with three/four on duty each day, two cooks and one kitchen assistant. In addition there is a full-time registered manager in post. At the last inspection concerns had been raised regarding carers working long hours. The manager assured us that this has ceased as the home now has additional staff thus giving more flexibility. They told us that full-time staff are contracted for 37-40 hours a week and they are only allowed to exceed this up to 42 hours a week. Care staff spoken said that their care hours were manageable and they did not feel pressured into doing additional hours. A Poplars DS0000017911.V371409.R04.S.doc Version 5.2 Page 21 carer who completed the staff survey for the Commission said that there was ‘usually’ enough staff on to meet the individual needs of the people who use the service. The manager told us that out of twenty-two staff, fourteen have either completed or are working on completing a National Vocational Qualification (NVQ) Level 3 or 2 in care. Seven of these staff members have already obtained a NVQ Level 3 or 2 in care and the manager said that the home is working towards 50 of their care staff with a NVQ Level 2 or equivalent. Within the AQAA it was stated that the home was looking for funding for care staff to complete both NVQ training and other relevant care training. The staff recruitment files of two care staff were sampled and inspected. Evidence was seen of good staff recruitment practices with records and checks in good order. All staff are expected to complete their Skills for Care induction training before commencing work and they are expected to ‘shadow’ a senior carer during this period. A newly recruited member of the staff confirmed that this was the situation and they told us of the training they had already completed as part of their induction training. They had completed the basic introduction into care, fire safety training and moving and handling training. Other basic training courses were to follow. They told us that they were getting to know the residents and had been introduced to their care plans. A carer who had completed the Commission ‘s survey said that their induction training had covered everything they needed to know ‘very well’ and they said that they were given the training they needed to do their work. The manager told us that the home has a training and development programme with basic training courses planned annually or every two to three years as required. The manager is qualified as a trainer for Moving & Handling and is a Fire Marshall and they told us that they are able to source training from within the company and externally. We were told of future planned training which were to include Moving & Handling, Fire Awareness, Food Hygiene, Safeguarding of Vulnerable Adults, Infection Control and First Aid. In addition eight carers who give medication had recently attended a Boots Medication training course. Poplars DS0000017911.V371409.R04.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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home should be assured of good management with an ongoing quality and monitoring system in place and health and safety systems to ensure that the people living in the home are protected. EVIDENCE: The manager told us that they had been employed within Southend Care Ltd. for eight years and had held a senior role for at least two years, before Poplars DS0000017911.V371409.R04.S.doc Version 5.2 Page 23 becoming the manager of Poplars in September 2004. They told us that they have completed a NVQ Level 3 in care and they have completed a NVQ Level 4 in care and management and a Train the Trainer course. This information was confirmed in the completed AQAA sent to the Commission. In addition in the last year they had attended training courses in Safeguarding Adults, Medication, Care Planning for Registered Managers, Supervision and they had attended a seminar in Pressure Care and Infection Control. They said that they had also completed Level 1 of the Deprivation of Liberty Training and they are planning to complete the second level of this course soon. They told us that they intend to update their training regularly so as they have updated their skills, knowledge and competence. Staff, residents and relatives made positive comments regarding the management of the home. They told us that the manager was available and approachable and should they need to speak with them they knew that they would be listened to and acted upon. A quality assurance and quality monitoring system is ongoing. In 2008 the home had surveyed residents and their relatives using a questionnaire, which covered topics under the National Minimum Standards headings. All of the responses receive were positive. Further quality audits had been completed in October 2007 and in November 2008 an Annual Monitoring visit had been conducted by Essex County Council and the home had complied fully. More recently the registered provider has introduced a monthly self-assessment to maintain quality of care within the home. The manager said that on completion this is sent to head office from where the home receives feedback. All of these processes help to ensure that the home is ensuring that the home is run in the best interest of the residents. The home holds personal money for all three of the people sampled. The records and money held was in good order, with records and receipts accurate providing a good audit trail. The manager demonstrated good practices in the management of this money. At this inspection we sampled the health and safety checks completed in the home. We saw records of hot water temperature checks, fire alarm and emergency lighting checks and records of quarterly fire drill instructions completed. These were in good order. Accident records were sampled and inspected and notifications as required under Regulation 37 of the Care Home Regulations 2001 were seen. These were compliant with requirements. Poplars DS0000017911.V371409.R04.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Poplars DS0000017911.V371409.R04.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Poplars DS0000017911.V371409.R04.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Poplars DS0000017911.V371409.R04.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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