Care Home: The Poplars Nursing Home

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What the care home does well People are able to spend time in the home before making a decision to move in and talk to other individuals and staff. As part of the assessment staff ask people how they want to be supported and write down this information. The bedrooms are all different sizes and a lot of rooms have been recently redecorated. People are able to bring furniture and personal items to the home.The Poplars Nursing HomeDS0000022360.V377735.R01.S.docVersion 5.2There are five main lounge areas and people like to sit with friends. When watching television people are able to decide which programme to watch and the screens are large with subtitles displayed. Family and friends can visit the home whenever they want to, and family members are able to continue to provide care for a relative and spend time in the home. People go out with family and friends and go on visits or shopping. There are activities arranged daily and individuals can choose whether to be involved. The planned meals are written on a board and displayed each day, so people can choose an alternative to the main meal being prepared. Food is served to people in their room or in the dining areas. People dress in their own style and if they need support, staff help individuals to apply make-up or to have a manicure. Staff provide any personal care and people in the home are well-presented and encouraged to take a pride in their appearance. Staff like to develop good relationships with people and will spend time talking and taking an interest in people`s lives and adventures. Staff have a good knowledge of the care needed and what people may want. People who use the service spoke highly of the staff and comments included, `the staff can`t do enough for you`, `the staff here are good and help you when you need them.` What has improved since the last inspection? There has been extensive redecoration around the home, which has made the home warm and welcoming to people. New equipment has been purchased in bedrooms and communal areas and specialist mobility equipment has been provided to met individual needs. The staffing provided has been reviewed and is flexibly organised to ensure it reflects people`s dependency levels and identified support needs. Additional staffing can be provided for special events and activities or when more support is required, this can be on a short or long term basis. Staff have an opportunity to attend training sessions and keep their knowledge and skills up to date. Staff can achieve a National Vocational Qualification by being assessed doing their actual work. This means staff can demonstrate they are providing a good standard of care.The Poplars Nursing HomeDS0000022360.V377735.R01.S.docVersion 5.2The menus have been reviewed with people`s preferences taken into account. There are fresh foods, vegetables and fruit available each day and people have a choice of meals. People spoke very positively about the standard of food provided. What the care home could do better: New care plans have been developed and these need to be implemented to ensure that people have individual plans of care. Within the dementia and nursing service, plans do not always record the care and support people need to ensure they are kept well and safe. Where specific health needs or support with managing behaviour has been identified, individual plans of care and assessments of risk need to be completed. This means that people can receive consistent appropriate care and the plans can be reviewed to ensure they are effective. Key inspection report CARE HOMES FOR OLDER PEOPLE The Poplars Nursing Home Rolleston Road Burton On Trent DE13 0JT Lead Inspector Mandy Brassington Key Unannounced Inspection 22nd September 2009 09:15 DS0000022360.V377735.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Poplars Nursing Home Address Rolleston Road Burton On Trent DE13 0JT 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) 01283 562842 01283 564642 Tawnylodge Limited Debbie Watson Care Home 60 Category(ies) of Dementia (60), Old age, not falling within any registration, with number other category (60) of places The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To increase DE beds from 5 to 60. The Registered Person may proved the following categories of service only: Care home with nursing Code - CHWN To service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP maximum number of places 60 Dementia Code DE maximum number of places 60 2. Dementia Code DE The maximum number of service users to be accommodated is: 60 Date of last inspection 3rd October 2007 Brief Description of the Service: The home is comprised of an extended two-storey building situated near to the town of Burton on Trent. The establishment provides personal and nursing care for elderly people with a bed capacity of 60. The home may also admit up to 5 people suffering with Dementia. There are forty-eight single and six shared bedrooms. Nineteen rooms have en suite facilities. The home has spacious accommodation, including 4 lounges on the ground floor and a further two upstairs. There is a bus service nearby and shops are nearby. The grounds and gardens are well maintained and provide easy access for wheelchairs. Weekly fees were not available within the Service User Guide. The reader may wish to approach the service to enquire about fees. The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was an unannounced key inspection and therefore covered the core standards. The inspection took place over 8.5 hours by one inspector who used the National Minimum Standards for Older Persons as the basis for the inspection. Prior to the inspection, the manager completed an Annual Quality Assurance Audit (AQAA) for us. There were questionnaires sent to people who use the service, professionals and staff members. We received four surveys from people who use the service and one survey from a health and social care professional. On the day of the inspection, the home was accommodating forty four people. We, the commission examined records, carried out indirect observation of seven people who used the service, and five staff on duty. Seven plans of care and four staff records were examined and observation of daily events took place. We spoke with nine people who use the service, two visiting relatives and two people providing activities in the home. We looked at five bedrooms, the five communal lounge areas, the dining room, the laundry areas and bathing facilities on all floors. We inspected the storage system and medication procedures. What the service does well: People are able to spend time in the home before making a decision to move in and talk to other individuals and staff. As part of the assessment staff ask people how they want to be supported and write down this information. The bedrooms are all different sizes and a lot of rooms have been recently redecorated. People are able to bring furniture and personal items to the home. The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.2 Page 6 There are five main lounge areas and people like to sit with friends. When watching television people are able to decide which programme to watch and the screens are large with subtitles displayed. Family and friends can visit the home whenever they want to, and family members are able to continue to provide care for a relative and spend time in the home. People go out with family and friends and go on visits or shopping. There are activities arranged daily and individuals can choose whether to be involved. The planned meals are written on a board and displayed each day, so people can choose an alternative to the main meal being prepared. Food is served to people in their room or in the dining areas. People dress in their own style and if they need support, staff help individuals to apply make-up or to have a manicure. Staff provide any personal care and people in the home are well-presented and encouraged to take a pride in their appearance. Staff like to develop good relationships with people and will spend time talking and taking an interest in peoples lives and adventures. Staff have a good knowledge of the care needed and what people may want. People who use the service spoke highly of the staff and comments included, the staff cant do enough for you, the staff here are good and help you when you need them. What has improved since the last inspection? There has been extensive redecoration around the home, which has made the home warm and welcoming to people. New equipment has been purchased in bedrooms and communal areas and specialist mobility equipment has been provided to met individual needs. The staffing provided has been reviewed and is flexibly organised to ensure it reflects peoples dependency levels and identified support needs. Additional staffing can be provided for special events and activities or when more support is required, this can be on a short or long term basis. Staff have an opportunity to attend training sessions and keep their knowledge and skills up to date. Staff can achieve a National Vocational Qualification by being assessed doing their actual work. This means staff can demonstrate they are providing a good standard of care. The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.2 Page 7 The menus have been reviewed with peoples preferences taken into account. There are fresh foods, vegetables and fruit available each day and people have a choice of meals. People spoke very positively about the standard of food provided. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3, 5, 6. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have information about the home and the service provided and can spend time in the home before deciding whether they would like to move in. There is a range of information about the home to support people to make a decision. EVIDENCE: People living in the home have a copy of the Statement of Purpose and Service User Guide in their bedroom, which provides details of the service provided, and the terms and conditions of occupancy. The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.3 Page 10 We examined seven records including two people who had recently moved to the home. Each person had been given a Service User Guide and had a contract with the fees payable. Discussion took place with the manager regarding providing this information in alternative formats, such as Easy Read and large print, and recording the information about fees within the Guide A Care Manager had carried out a single assessment identifying support needs and preferred outcomes for people, for people funded through the local authority. Prior to moving in to the home, an assessment is completed with the individual and family members, to determine whether the home is able to meet peoples needs. The assessment includes personal details, a history, personal preferences and interests and support required. The manager reported that wherever possible individuals visit the home and meet other people and have lunch at the home. Individuals confirmed they were involved in the assessment process and were also able to look around the home and view vacant rooms. Discussion with two people who used the service reported that family members had looked around the home as they were in hospital, but they were able to visit other places upon admission to ensure they were happy with their decision. One completed survey commented, we looked at several homes, and this one stood out, we know we made the right decision. Within the AQAA, the manager recorded that Social Service staff and Mental Health teams know our staff can cope well with emergency admissions due to previous experience. Discussion took place with the manager and family members who had experienced an emergency placement, who stated that it was difficult for all people concerned initially, due to the very short notice but they had worked together and improved communication to ensure the person was suitably supported The home does not provide intermediate care. The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.3 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 7, 8, 9, 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use service are able to continue to see health care professionals to make sure their health needs are met. Plans of care are being developed to ensure they are individual and people are receiving suitable support. EVIDENCE: We examined seven plans of care within the residential and nursing service. The plans within the residential service recorded information about the support they require with personal and health care. Three plans for people who had lived in the home for a significant period of time, included information about the support people wanted for bathing, eating and drinking, personal hygiene The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.3 Page 12 and mobility, personal safety and health needs. Information was available regarding assessments of risk for any identified concern and mobility. This information means that all staff are aware of how to support people. Two plans were for people who had recently moved to the home. A preadmission assessment had been carried out and a basic plan recording preferences for daily support had been completed. Information about health care visits and any appointments were recorded along with details of any relevant information. People were able to receive support from family members or staff to ensure health care needs are met. During our visit people were observed attending the local hospital and community transport or ambulances had been provided. The nursing plans of care were generic and each person contained a preprinted care plan with their name completed. Where this plan differed according to individual needs this had been amended. The plans were discussed with the manager as they were not person centred and did not record peoples individual care and support needs. Within the service for people with dementia, one person received nursing care for pressure sores. A Body map had been completed to identify where the sores were, but no plan had been written to demonstrate the care the person required and information regarding tissue viability. A short daily record noted that care had been provided but not how, and there was no review of the treatment. Discussion with staff confirmed that a plan had not been completed and all information was shared verbally. This means that the person may not be receiving suitable care at a time and method that promotes their health. One plan identified that a person could be verbally and physically aggressive and self harm. The plan of care did not record any specific details regarding the aggression, risk to the person or others and how the team of staff would consistently manage any behaviour. Inspection of the Medication Administration Record (MAR) identified the person was administered medication to support management of aggression on several occasions the previous weeks. Inspection of daily records identified that there was only brief information about any behaviour, and for some days no entry was recorded. The nurse confirmed that there was not a prn (as required) protocol in place to guide staff as to when the person needed the medicine. This means that the person is not supported to manage any behaviour and may pose more of a risk to staff and other people. As there is no plan available the effectiveness of the management plan and medication regime could not be reviewed to ensure the person is suitably supported. The week prior to our visit senior staff had attended training around a new care plan system; including assessing and completing the new care plans. The manager showed us the new plans which included personal information, clearer The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.3 Page 13 information about support and care needs, historical information and details required to address the Mental Capacity legislation and recording information about decisions and a persons capacity. The plans were discussed with the manager and the need to prioritise implementing these to ensure Person centred plans are developed, to reflect how people are to be supported to remain safe and manage any identified behaviour, and receive nursing care. We will review the plans in our next visit to ensure the service has recorded this information and providing person centred plans. Each person has a Key Worker who reviews the plan each month and changes to the plan had been recorded. During discussion, staff demonstrated a good knowledge of peoples needs and were observed providing sensitive care throughout the visit, including talking to people about what was happening, and giving choices. People in the home were well presented, wearing their own clothes, which were ironed and clean. One relative commented, The hygiene of people and cleanliness is first class. Medication was stored appropriately in the home and observation of medication practices revealed that people were offered a drink with medicines and given time to take them at their pace. Medication Administration Records (MAR) were completed appropriately for dispensing medication. Hand written entries on the MAR Sheets were recorded by two people to ensure accuracy. A number of medicines were stored within a secure fridge. A record of the maximum and minimum temperatures had been recorded daily. A sample inspection was carried out for the Storage and receipt of Controlled Drugs, and found good systems in place. The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.3 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are involved in daytime activities of their own choice in the home and the local community. Individuals can welcome family and friends into the home throughout the day, who can join any activity or event. EVIDENCE: The AQAA recorded that the home provides a varied programme of activities and people are able to choose whether to participate. On the day of our visit, a Bible Class was organised in the morning. Discussion with the host reported that the session was usually well attended and people were able to discuss religious and social issues. If people were unwell and in bed, the host would visit people and have prayers. Four people who use the service stated that religion and attending church had played an important part in their lives and The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.3 Page 15 they enjoyed attending the bible classes and services. Two people reported that they continue to attend their usual place of worship. One person commented I love going to church, and its always nice to see friends there. Pictures are displayed in the home of activities. Any planned activity is recorded on the Notice Board and in the Entrance Hall. Outside the dining room is an activity corner with memorabilia and objects relating to a specific topic, which at the time of our visit was old school days. The manager reported that this often stimulates conversation at meal times. The service has an activities coordinator who has sought the views of people and plans activities according to peoples interests and hobbies. People who use the service and staff revealed that other regular activities include knitting groups, arts and crafts, musical entertainment, bingo, games and manicures and hand massages. There are five lounge areas around the home on two floors. Most rooms have a large screen television which has subtitles displayed to support peoples viewing. One person commented we sometimes sit and chat in the rooms or watch television, though its nice to be able to go your room and just read sometimes and we generally get on really well and some of us were already friends, which is nice. Visitors were observed coming to the home throughout the day and discussion with people confirmed they are able to have visitors at any time. Many people spoke about going out with family and friends to visit places of interest. Staff reported that they are able to support people to go out in the community to go shopping or to visit people. There have been two trips out this year to Calke Abbey and to a Large garden Centre. Lunch was shared with people who use the service. A menu is displayed on a large chalk board in the dining. On the day of the visit, lunch was pork chops or liver and onions with vegetables and potatoes, and dessert was egg custard, an alternative was available upon request. People spoke highly of the meals served. Comments included, you just cant fault the food, and the food is always good here, were very happy with it and you always have a choice. There is a menu comment book in the dining room if people wish to make any comment about the standard or choice of food; the manager reported that the menus are reviewed accordingly. The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16, 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are given information to make a complaint so that where any concern is identified they are confident this will be acted upon. Staff are knowledgeable about how to protect people to ensure people are safeguarded. EVIDENCE: The home has a Complaints Procedure, which is displayed in the home and within the Service User Guide. There have been two complaints made since the last visit to us which were investigated to a good standard. The manager reported that the service acts on all complaints and concerns identified and discussion with relatives confirmed that one concern raised had been managed. It is recommended that where verbal complaints and concerns are raised, these be recorded along with any outcomes. Discussion with people who use the service revealed they would report any concerns to the staff or manager. The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.3 Page 17 The home has policies and procedures for safeguarding people in the home and staff have received training for recognising signs of abuse and reporting possible abuse. During discussion, staff identified a good knowledge of how to safeguard people and what they would do if they suspected abuse. The service has a whistle blowing Policy and staff stated they are confident the manager and service providers would ensure this was followed to safeguard them. Small amounts of money can be surely held in a safe and a record of monies and valuables are maintained and audited. The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 23, 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to decorate their room with personal possessions so that it is comfortable and pleasing to each person, and use personal equipment to ensure they are safe and supported. EVIDENCE: During our visit we looked around the home including lounge areas, dining rooms, bathrooms and bedrooms. The manager reported within the AQAA and during our visit that since the new ownership of the home, extensive The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.3 Page 19 redecoration had taken place around the home and new furniture had been purchased. Many of the bedrooms have new beds, bedroom furniture and new bedding; the bathrooms are being upgraded and new commodes have been purchased, the laundry facilities have been upgraded and the manager reported that the kitchen is to be refurbished later this year. Individuals are able to bring in small personal belongings to the home, and many people had chosen to decorate their room with photographs and personal pictures, and had a television or radio. Some people living in the nursing service had chosen to have there bedroom door painted a different colour, and there is a small box outside each door, which can be filled with personal items to help people identify their room. On the ground floor there is a door leading from the main residential area that is sometimes closed, to ensure peoples safety. This was discussed with the manager and staff to develop a protocol and assessment of risk to identify when it is suitable to close the door, and how staff ensure this does not deprive others from using all facilities within the home. Environmental Health conducted a visit in April 2009 and awarded the home three stars. The requirements made in this report regarding cleanliness have been addressed and the manager reported that a new cleaning roster is now implemented. The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29, 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to have confidence in the service provided as staff receive ongoing training needed to support people. There is a good recruitment procedure to ensure that people are suitable to work in the home. EVIDENCE: On the day of the visit there were seven staff on duty on each shift and the manager works across the shifts in a supernumerary capacity. There were forty four people residing at the home within the residential and nursing service, and the manager reported that the peoples needs could be met within the current staff group. Staffing is organised flexibly to meet identified needs and where occupancy levels increase or decrease the staffing reflects this. We examined four staff files that demonstrated the homes recruitment procedures were of a good standard. All individuals completed an application form, two written references were obtained along with a copy of identity, a The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.3 Page 21 PoVA First (Protection of Vulnerable Adults) and a Criminal Records Bureau Check (CRB) were obtained. Staff reported that they received an Induction when starting to work at the home and shadowed staff for up to a month. Within the AQAA the manager reported that the staff complete The Common Induction Standards and after completing this, staff have an opportunity to gain a National Vocational Qualification (NVQ). The AQAA stated that since the last visit eleven carers have started a National Vocational training Certificate, which means people gain an award by being assessed doing their actual job. Staff reported they were valued by the new management team, and one person reported, I feel proud to work here now, its a pleasure to come to work. The manager reported that the training and support provided by the management team meant that people who used the service benefited from a high staff morale and from people maintaining up to date skills. Staff reported that since the new management of the home they had been able to attend a large amount of training including moving and handling, dementia, fire safety, and infection control. Staff reported they valued the training which had given them an opportunity to develop their skills and keep up to date with practice. Discussion with staff and from observation of daily events revealed that people were sensitively supported. People using the service spoke very highly of the staff and the support provided. Comments included, the staff cant do enough for you, staff are always available, and the staff here are good and help you when you need them. The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 33, 35, 36, 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to benefit from a professional management approach and a supported team, as the manager has a clear understanding of the key principles and focus of the service. The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.3 Page 23 EVIDENCE: It is evident from observation and discussion with staff, that the manager is enthusiastic and committed to promoting peoples rights and providing a good service. The manager is open and transparent in all areas of managing the home. Staff and people who use the service commented they would have no hesitation approaching the manager. Prior to the Inspection, the manager completed an Annual Quality Assurance Audit (AQAA) for us. The AQAA contained clear, relevant information that was supported by a wide range of evidence. The AQAA identified the changes that had been made since the last visit, and where they still need to make improvements. Evidence within the AQAA was sampled and found to be accurate. There have been new owners of the home and the manager and staff reported that there has been extensive improvement with the physical environment, equipment provided and quality of management and support. Staff reported they were valued as a team and had opportunities to develop their skills and competence to be able to provide a good service in the home. The service has a quality assurance programme which is carried out on an annual basis. This includes gaining the views of people who use the service, friends and relatives and health and social care professionals. A report is completed along with an action plan and this is made available to people. The registered person or a representative visits the home on a monthly basis and completes a report about the visit. The reports include information about the experiences of people and any planned improvements. This means that people can be confident the registered people are taking an interest in the home and maintaining the service to a suitable standard. The manager and staff are promoting positive beliefs for equality and diversity issues, especially in relation to gender and religion. Staff are aware of how peoples beliefs can impact on care and support, and are working closely as a team to act as a positive role model. The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.3 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 3 3 3 X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 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 3 3 X 3 3 X 3 The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.3 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. 1 Standard OP7 Regulation Reg. 15(1) Requirement Regulation 15 (1) Person centred plans must be developed to reflect how the person would like and need their support to be provided. Where a health need is identified, the plan needs to contain how a person is to receive support and any nursing intervention. This will ensure that people receive consistent and appropriate nursing care. 2 OP7 Reg. 15(1) Regulation 15 (1) Person centred plans must be developed to reflect how people are to be supported to remain safe and manage any identified behaviour. The plan needs to record any behavioural management strategy and assessments of risk. The plan needs to be kept under review to ensure its continued effectiveness. The Poplars Nursing Home DS0000022360.V377735.R01.S.doc Version 5.3 Page 26 Timescale for action 23/10/09 23/10/09 This will ensure that people receive consistent and appropriate safe support. 3 OP9 Reg. 13(2) Regulation 13 (2) Proper arrangements must be made for the safe administration of medicines where as required medication is prescribed. A clear medication protocol is to be in place to identify when this should be administered. This will ensure that the person only receives the medicines as directed and at a suitable time to keep the person safe and well. 23/10/09 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 OP1 OP1 Good Practice Recommendations The Service User Guide should include details of the fee level to ensure people have accurate information about their contribution. The Service User Guide should be developed to other suitable formats to ensure people who use the service and prospective residents have clear accessible information about the home and the service provided. A new care plan format has been developed. This should be implemented to ensure people have a person centred plan and all relevant information is recorded to reflect how the person likes and needs their support to be provided. To record all concerns and complaints and outcomes of any investigation or changes to demonstrate the service is responding to individuals. To develop an assessment of risk and protocol for closing the door within the residential service to demonstrate when this is to be closed and how people are not being restricted. DS0000022360.V377735.R01.S.doc Version 5.3 Page 27 3 OP7 4 5 OP16 OP19 The Poplars Nursing Home Care Quality Commission Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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