Care Home: Poppy Lodge

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What the care home does well The people living in the home continue to live in a homely, well maintained environment that meets their needs. There is a homely environment in which the people living in the home feel safe to talk about their feelings. Everyone is treated like an individual and there are good relationships with relatives and other people involved in the care of the people living in the home. The people who work in the home have worked there a long time and know the people living their well. They know how they want to be helped.People living in the home are given choices about food, what to wear, where to sit and what to do. What has improved since the last inspection? Since the last inspection a lot of changes have been made to the building. Everyone living in the home now has a bedroom where they have their own toilet and shower. The home has been decorated throughout and some new lights and furniture has been bought. The front garden has been made safe. CARE HOME ADULTS 18-65 Poppy Lodge 633 Church Road Yardley Birmingham West Midlands B33 8HA Lead Inspector Kulwant Ghuman Key Unannounced Inspection 6th May 2008 10:00 Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 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 Poppy Lodge DS0000017128.V364138.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 Adults 18-65. 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. Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Poppy Lodge Address 633 Church Road Yardley Birmingham West Midlands B33 8HA 0121 628 3718 F/P 0121 628 3718 poppylodge@yahoo.co.uk 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) Mrs Saeeda Younus Mrs Saeeda Younus Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 29th May 2007 Brief Description of the Service: Poppy Lodge is currently registered to provide accommodation, care and support for 6 people with learning disabilities. The Registered Manager is also the owner of the Home. At the present time, all of the people living in the home are male. The property is a large detached house situated in the residential district of Yardley in Birmingham. A range of local amenities and community facilities are available close by, and the house is well served by public transport. On the ground floor there is a through lounge / dining room which gives access to the rear garden through patio doors. There is a smaller quiet lounge on the ground floor. There is a homely kitchen and laundry facilities are available on the ground floor. There are two downstairs bedrooms with en-suite showers and toilets and a separate communal toilet. Upstairs there are four single bedrooms. All the bedrooms have their own en-suite facilities. There is a communal bathroom available on the first floor. The main office and sleeping in rooms are based on the first floor. At the front of the house is a good-sized drive offering off-road parking. To the rear of the property is a large private garden. Specific fees are not identified in the service user guide but it states that the fee payable is according to the adults with specific needs contract. Poppy Lodge DS0000017128.V364138.R01.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 star. This means the people who use this service experience good quality outcomes. One inspector carried out this key unannounced inspection over a day during May 2008. Before the inspection the home had provided the CSCI with information by way of the Annual Quality Assurance Assessment (AQAA). Surveys completed by the people living in the home, their relatives and one professional also provided the inspector with information on which to base the inspection. The inspector was able to speak with the manager, two members of staff, one relative and three of the people living in the home, looked around the building and sampled some records. Inspectors who were carrying out inspections at the time of this inspection were asked to collect some specific information to find out if people living in care homes were being kept safe. To do this the inspector asked specific questions to find out whether staff in the home understood how to keep people living in the home safe from harm and also looked at some of the policies and procedures. Some of the people living in the home were also asked if they knew who to turn to if they were not feeling happy about something happening in the home. There had been no complaints and no adult protection issues raised about the home since the last inspection. What the service does well: The people living in the home continue to live in a homely, well maintained environment that meets their needs. There is a homely environment in which the people living in the home feel safe to talk about their feelings. Everyone is treated like an individual and there are good relationships with relatives and other people involved in the care of the people living in the home. The people who work in the home have worked there a long time and know the people living their well. They know how they want to be helped. Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 Page 6 People living in the home are given choices about food, what to wear, where to sit and what to do. What has improved since the last inspection? 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. Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. No admissions had been made to the home but the manager was aware of the process to be followed before anyone else moved in. EVIDENCE: Service user guide does not have the exact fees in it but does refer to the Adults with specific needs contract. Information is available for people to make a decision about whether they should move into the home or not. This information needed to be updated since a lot of changes had been made to the building. No new admissions to the home since 2005. No one has moved out so there is a family feel about the home. The home will be admitting to two new bedrooms recently added to the home and the manager was very clear that only the right individuals would be admitted to the home. She was well aware for the need to follow the admission process and gather sufficient information about the individuals before agreeing to let them move into the home. Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living in the home knew that they each had a file telling the staff about how to help them and they were asked about the things that they liked to do. Different people in the home did different day-to-day jobs to help around the home. EVIDENCE: The care plans had not changed since the last inspection. There was some good information in them including background, profiles and details of how individual needs were to be met. The working care plan covered areas such as personal care, incontinence, dressing, behaviour and activities. The file of one of the people living in the home was looked at. It made good use of pictures so that the individual could also understand it. Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 Page 10 The file contained information that the people who worked in the home needed to know to help the individual look after him. It recorded the things that he liked to do and how staff could help him. One of the people who lived in the home told the inspector that he was very happy at the home and that he was glad that his passport had been sorted out so that he could go and visit some of his relatives. He told the inspector about the plans that had been made to do this. The people living in the home can do a lot of things for themselves but need to be reminded about what to do. Every month the people who work in the home talk about and write down what has been going well for the people and what has not. This can help them to make changes to the way that they help the people who live in the home. There were risk assessments in place that explained where there could be a danger to the people living in the home and how they could be helped. One of these plans described whether the person could move around with or without help, and what help might be needed. These risk assessments were also mentioned in the care plans so that the people working in the home knew what to be careful about. The people living in the home could tell the manager if they wanted a man or woman to help them or if they didn’t mind who helped them. They could also decide whether they wanted to have the keys to their bedroom doors and if they were able to take responsibility for their own medicines. The staff in the home talked to the people living there and asked what they wanted to do, what they wanted to eat and where they wanted to go on holiday on a one to one basis but there were not many meetings to make decisions that had to be made by people who were living together. The inspector advised the manager that it would be useful to have more meetings, perhaps on a weekly basis to decide things such as what food they were going to eat and the things they were going to do during the next weeks. This was going to more important as it was likely that more people would be moving into the home over the next few weeks. Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15 , 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are able to choose how to spend their days and feel a part of the home. EVIDENCE: There were a variety of things for the people living in the home to do depending on what they wanted to do and what they could do. The staff told the inspector that they read the daily newspaper with one of the people living in the home during each morning. They all go out shopping on a Saturday and have a meal while they are there. They can go to the pub or bowling in the evenings if they want to but they can stay at home if they don’t want to go out. There was on person living in the home who was spending quite a lot of time at home as an alternative day centre had not been found for him. Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 Page 12 Sometimes the people living in the home liked to sit with the other people living in the home but sometimes they liked to spend time alone in their bedrooms listening to the radio or watching their own televisions. Some of the people have their own jobs to do around the house such as helping to lay the table for meals, putting the rubbish bags out and filling and emptying the dishwasher. Depending on how safe it was for individual people to be in the kitchen some of them were able to make things like sandwiches or cups of tea for themselves. One of the individuals had been out to see a relative during the day and was able to go out by himself and was able to use the buses. Another person told the inspector about his girlfriend who he saw regularly. The inspector saw one relative at the home during the inspection and was told that they regular visited the home and were happy with the way the people living in the home were being looked after. They also mentioned how nice the home was looking. Holidays were being arranged and the inspector was told about trips to Ireland and Blackpool that were being arranged. The inspector looked at the menu and the papers that showed what people were having to eat. People living in the home could sometimes have a cooked breakfast. The teatime meals were quite varied but the lunchtime meals did not appear to be very varied. The majority of the time sandwiches were served at lunchtime. There were some occasions when something else was given. This issue was discussed at the last inspection and although there may be certain people who always want to eat the same things this should not mean that everyone has to eat the same things. This is one of the reasons why it has been suggested that the home discuss the meals on a weekly basis with the people living in the home. Also by having different things served it may encourage the particular individual to try different things when he sees other people eating them, if not, it would not be too difficult to make a sandwich for him. Even if the individuals were occasionally having different things to eat this was not being recorded in the records. At the time of the inspection there was food available in the home but the stocks were very low. The manager told the inspector that the stocks had been allowed to go low purposely so that the fridge and freezers could be defrosted. They were due to go shopping the day of the inspection. This was Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 Page 13 confirmed as one of the people living in the home was well aware that he was supposed to be going shopping with the manager. Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care was provided in the way individuals wanted and their healthcare needs were being appropriately met. EVIDENCE: The people who live in the home were given help to undertake their own personal care. Most of the people living in the home could do most things for themselves but needed to be reminded to do things. As part of the inspection a survey was sent out to the people living in the home and people involved in their care. The following were some comments made by these paper: “I have seen you two look after me and care for me” “There is a cleaner who comes every day and I have a wash every day” “ I do not go into the home but I would like to commend you and your staff on the obvious care and concern that your residents receive. They are always clean and appropriately dressed and obviously well looked after when you bring them to the surgery. You care about their general health and keep a Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 Page 15 check on their weight, making changes to their diet and exercise programme if necessary.” The files that the inspector looked at showed that the people living in the home were seen regularly by doctors and nurses. There were health action plans in place to ensure that health needs were regularly followed up and responsibilities allocated. One of the people living in the home told the inspector how he and the manager used to go walking so that they could lose weight. The people living in the home could talk about all sorts of issues with the people who worked in the home. The inspector was also told how he was taken to his mother’s grave and how he had been able to spend time there talking to her which made him feel better. The people living in the home were taken to the doctor and hospital appointments as needed. There was no-one living in the home who was able to look after their own medicines. There was very little medicine in the home. The majority of the medicines in the home were in a monthly blister pack and this made their administration much easier. There was some medicine in the home that should have been returned to the pharmacist a long time ago as it was no longer needed. This and another medicine had not been recorded on the medicines charts (MAR). the inspector knew that these medicines had not been given to anyone as the number sent by the pharmacist were still in the boxes. One medicine that had been prescribed for one of the people living in the home had then been written up on one of the MAR charts suggesting that anyone in the home could be given this medicine. No one had been given the medicine as the seal on the bottle had not been broken yet. Medicines prescribed for one person are the property of that individual and it may not be appropriate or safe to be used by others. Other than these couple of errors in the management of medicines the medicines were well managed and the people living in the home were getting the medicines as prescribed. Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living in the home were safe and knew who to turn to if they were unhappy about anything. EVIDENCE: Inspectors who were carrying out inspections at this time were asked to collect some specific information to find out if people living in care homes were being kept safe. To do this the inspector asked specific questions to find out whether staff in the home understood about how to keep people living in the home safe from harm and also looked at some of the policies and procedures. Some of the people living in the home were also asked if they knew who to turn to if they were not feeling happy about something happening in the home. Two of the staff and the manager were spoken with and it was found that even if the staff did not always understand some of the terms being used they were aware of what to do to keep people in the home safe. They were aware of the policies and procedures in the home and where they were kept. They also said that they had had training about this topic. It is recommended that the policies and procedures are discussed with staff on a regular basis to ensure that their understanding of the issues and what to do if an issue were to arise remains clear in their minds. There had been no complaints in the home and the commission had received no complaints since the last inspection. It was suggested that any grumbles Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 Page 17 from staff, people living in the home or visitors were recorded so that appropriate actions could be taken to improve the situations. Since the last inspection a complaints procedure that was easier for the people living in the home to understand had been made available. Comments made by two of the people living in the home were: “would speak to the manager or staff if unhappy”, and “I can shout and make noise and ask for help and ask manager and my family for help.” Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is safe, comfortable, and clean and meets the needs and preferences of the people living there. EVIDENCE: The building works that were underway at the time of the last inspection had been completed and two new bedrooms had been registered so that the home was able to have up to 6 people living in the home. The home had been decorated throughout, with new carpets in most areas, new curtains and new furniture. The bedroom furniture was waiting for locks to be fitted to the bedside cabinets. New lighting had been installed and all radiators had been guarded. All the people living in the home now had ensuite facilities and there were some communal toilets and bathroom available. Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 Page 19 On the ground floor there was an additional quiet lounge to be used by visitors if needed. The front garden had been landscaped so that vehicular access was easier and the area safe from hazards for the people living in the home. The rear garden could be accessed from the dining area and there was a patio area that could be used in the warm weather. All the bedrooms were individualised and contained personal belongings. Everyone living in the home said they were happy with their bedrooms. Information provided by the home indicated that the new rooms had been built to meet current standards and that anti-scalding devices had been put in place to safeguard the people living in the home. A new boiler had been fitted and the whole house had been decorated according to the preferences of the people living in the home. One of the people living in the home told the inspector that he had chosen the colour of his bedroom. The home was very clean and comfortable and there were no offensive odours. Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were adequate numbers of staff on duty to meet the needs of the people living in the home but the staffing rotas did not always reflect who was on duty. EVIDENCE: There was quite a small staff group in the home and they had all worked there for some time and they knew the needs of the people living in the home. The interactions between the staff and the people living in the home were good. They were friendly but professional and succeeded in providing a homely environment. The information provided by the home before the inspection told the inspector that 60 of the staff had got NVQ level 2 and that the rest were working towards it. Since the last inspection training had been arranged in fire safety, food hygiene, medication, manual handling, adult abuse, epilepsy awareness and first aid. Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 Page 21 There was a good mix of staff backgrounds and ages. There was one male carer and domestic assistant in the home to help reflect the gender of the people living in the home. The recruitment files of three staff were sampled. Two of them had worked in the home for some time and one had been recently employed. Where staff have been in post for some time and had not had CRB clearance since being employed in the home it was recommended that these were obtained. It was also advised that in order to ensure equality all new staff complete application forms and two references are taken up even if the manager knows them. Induction must also be carried out for all staff to ensure that the people living in the home are safe. The inspector was told that there was always one member of staff on duty in addition to the manager and there was a sleeping in member of staff in the home. The staffing rota was sampled and discussed with the manager as it was not always a true reflection of who was on duty. There were occasions when no night staff were indicated however, recordings showed that there was someone on duty. Also during the daytimes, the rota sometimes show that one person is on duty but another individual signs the daily records. On some occasions who was on duty could not be determined as daily records had not been written up. Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living in the home benefit from the knowledge and leadership of the manager and live in a safe and fulfilling environment. EVIDENCE: It was clear from discussions with staff and people involved in the care of the people living in the home that the needs and well being of the people living in the home was the highest priority in the home. There were good relationships evident between the staff, people living in the home and visitors to the home. There was good leadership from the manager who clearly saw the happiness of the people living in the home as being of utmost importance. Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 Page 23 The manager had recently carried out some surveys asking for views from different people involved in the care of people living in the home including day centres, health professionals, relatives, staff and social services. The majority of responses were very positive and it was pleasing to note that were improvements had been identified these issues were being proactively followed up either by undertaking corrective actions straight away or by arranging a meeting to discuss the issue further. The manager was aware that she was yet to write up a report encompassing these findings and the actions that were being taken in response. The manager looked after small amounts of money for the people living in the home and the records for the management of the monies were good. One individual continued to manage their own money and the relative of another managed their finances. Health and safety was well managed in the home and all equipment was regularly serviced and maintained. The people living in the home were regularly involved in fire drills in the home and were clear about what to do if the alarm sounded. Poppy Lodge DS0000017128.V364138.R01.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 Adults 18-65 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 2 X 3 X 4 2 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 3 3 X LIFESTYLES Standard No Score 11 2 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 YA17 Regulation 17(2) Sch 4(13) Requirement The registered person must ensure that varied and nutritious meals are available at all meal times. Timescale for action 01/07/08 2. YA20 13(2) This will ensure that the people living in the home have choices and receive all the nutrients they need to remain healthy. There must be a clear audit trail 01/07/08 for all medicines received into and leaving the home. (Previous timescale of 01/07/07 not met.) The registered person must ensure that all medicines not needed are returned to the pharmacist. The registered person must ensure that medicines prescribed for one person are not given to another person. This will ensure that the people living in the home receive their medicines as required. The manager must ensure that DS0000017128.V364138.R01.S.doc 3. YA34 19 01/09/08 Page 26 Poppy Lodge Version 5.2 Sch 2 all staff have a valid CRB clearance in place. 4. YA35 The recruitment procedure must be fully followed for all staff. 18(1)(c)(i) The registered person must ensure that all staff have been given induction training suited to their roles. This will ensure that the people living in the home will be safe. The registered person must ensure that there is an accurate copy of the duty roster of persons working in the home and a record of whether the roster was actually worked. This will ensure that there are always appropriate staff on duty. 01/07/08 5. YA42 17(2) Sch 4(7) 01/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations The service user guide should be updated to reflect the changes made to the home. This will ensure that people have accurate information about what is available in the home. There should be more regular meetings with the people living in the home. This will ensure that they make meaningful choices on a regular basis. The manager should discuss the multi-agency guidelines on adult protection with staff on a regular basis. This will ensure that the staff are reminded of the procedures and their responsibilities. There should be one piece of lockable furniture in the bedrooms. This will ensure that the people living in the home have somewhere they can keep things important to them safe. DS0000017128.V364138.R01.S.doc Version 5.2 Page 27 2. 3. YA16 YA23 4. YA26 Poppy Lodge Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Poppy Lodge DS0000017128.V364138.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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