CQC report explained · a residential care home
What the CQC found at Poplars Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found enough staff, suitable risk assessments, safe medicines processes and infection control arrangements, but made two recommendations about fire and water safety.
- Effective?
- Good
- This area was not covered by this focused inspection.
- Caring?
- Good
- This area was not covered by this focused inspection.
- Responsive?
- Good
- This area was not covered by this focused inspection.
- Well-led?
- Good
- The home had effective management arrangements, listened to people and staff, and used audits and an improvement plan to track actions.
What inspectors found, July 2022
Rated Good, improved from Requires Improvement; inspectors found safe, caring support but made two recommendations about fire and water safety checks.
This was an unannounced focused inspection on 4 July 2022. The inspector spoke with five people, one relative and six staff. They observed care, checked the home and reviewed care, medicines, recruitment and management records.
The home was rated Good overall, with Safe and Well-led both rated Good. People said they were happy, felt safe and could get help when needed. Inspectors found enough staff, safe medicines processes, risk assessments and systems for safeguarding and infection control.
The inspectors made two recommendations. The home should review when a new fire risk assessment is needed and how water temperature probes are used. A damaged fire door mechanism and a missing risk assessment for partial self-medication were addressed during or after the inspection.
People felt safe and happy
People said they were happy with the care and felt safe. Inspectors also found that people could raise concerns and that managers listened.
“People were happy with the quality of the care provided.” from the report
Enough staff
People and staff said staffing levels met people's needs. Inspectors saw staff were busy but not rushed, and the home used dependency information when planning staffing.
“People and staff reported there were sufficient staff to meet people’s needs.” from the report
Risks were managed
The home assessed risks such as falls and pressure ulcers. Staff had guidance and training to support people safely.
“Where risks had been identified appropriate measures and detailed staff guidance were in place” from the report
Open management
People, relatives and staff could share their views directly with managers. The home used feedback to make changes, including to activities and the menu.
“The provider was open and receptive to feedback and keen to identify any areas they could improve.” from the report
Learning from incidents
The home reviewed incidents and used the findings to arrange further staff training when needed.
“The provider told us following their review of an incident and the contributing factors, additional training had been arranged for staff” from the report
Fire risk assessment
minorThe internal layout had changed since the last fire risk assessment. Inspectors recommended checking whether a new assessment was required.
“We recommend the provider reviews the guidance about when to update fire risk assessments and consider if a new fire risk assessment is required.” from the report
Water temperature evidence
minorThe home was checking tap water temperatures, but the readings were below 44 degrees because of the thermostatic mixer valves. Inspectors recommended reviewing how temperatures are checked before the valves.
“We recommend the provider review guidance about the use of water temperature probes as a means to test the hot water temperature at the pipe inlet to the TMV's” from the report
Self-medication risk assessment
needs fixingOne person's care plan did not assess the possible risks of taking medicines without staff observation. The provider acted immediately after inspectors raised this.
“We brought this to the provider's attention, who immediately took appropriate action to address this.” from the report
One missed COVID-19 testing requirement
minorRecords showed that one staff member had not followed testing requirements after recovering from COVID-19. The report says this was addressed after the visit.
“Records of staff testing showed all staff but one had accessed COVID-19 testing correctly.” from the report
- 01What action has been taken following the recommendation to review whether a new fire risk assessment is needed?
- 02How do you now check and record hot water temperatures before they reach the thermostatic mixer valves?
- 03How do you assess the risks when a resident wants to take some or all of their medicines without staff observation?
- 04What arrangements are in place to cover staff sickness and holidays?
- 05How do you use feedback from residents and relatives to make changes?
This was a focused inspection of Safe and Well-led only; the report does not provide fresh findings or ratings for Effective, Caring or Responsive. This explanation was written from the published report of 21 July 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, May 2020
Rated Requires Improvement; inspectors found kind, personalised care and major progress, but safety checks and leadership still needed strengthening.
This was an unannounced follow-up inspection on 26 February and 3 March 2020. Inspectors spoke with people, relatives and staff, observed care and activities, checked the building, and reviewed care, medicine, staff and management records.
The home had improved significantly since its previous inadequate rating. Staffing, care records, medicines management, cleanliness, activities and staff training had improved. People were generally treated kindly and with dignity, and their care was personalised.
Some risks remained. Falls were not always reviewed fully, drink choices and independent access to snacks were limited, and quality checks did not identify every safety issue. The ratings were Good for Effective, Caring and Responsive, and Requires Improvement for Safe and Well-led.
Improved staffing
Staffing levels had increased, including extra support in the afternoons. Inspectors saw staff were busy but had time to meet people's needs.
“We observed lunch and dinner times and staff were busy, but not rushed and had time to meet people's needs.” from the report
Kind and respectful care
People were treated with dignity and staff were generally patient, caring and respectful. Relatives and people also gave positive feedback.
“Staff were patient and unhurried when supporting people, for example one member of staff was helping someone to eat their lunch.” from the report
Personalised support
Care plans included people's histories, preferences, cultural and religious needs, interests and abilities. People and relatives were involved in planning care.
“People's support plans were personalised and included their personal history, cultural and religious needs.” from the report
More activities
The home had expanded activities for different abilities and interests. Staff also supported people to take part in suitable activities in the community.
“There was an activities co-ordinator who worked part time at the home.” from the report
Improved medicines management
Medicine storage, administration records and staff competency checks had improved. Staff explained medicines to people before giving them.
“All staff administering medicines had completed a competency assessment.” from the report
Falls were not fully investigated
needs fixingReviews did not always examine the surroundings or likely causes of falls. Inspectors recommended using national falls guidance.
“Reviews of falls incidents were basic and did not always look at environmental factors or the cause of the fall to understand if these could be reduced.” from the report
Limited drink and snack access
needs fixingPeople had food and drinks, but the choice of drinks was limited. Some people could not independently get a drink or snack because staff considered the kitchen unsafe.
“We recommend the service review facilities around eating and drinking to provide better access for people to make their own drinks or snacks and offer more choice.” from the report
Quality checks missed some risks
needs fixingAudits had improved but did not identify every safety issue. Inspectors found exposed wiring and areas with poor lighting or a possible collision risk, which managers acted on.
“However, we felt further improvements were required to ensure all aspects of health, safety and wellbeing were being identified through these reviews.” from the report
Medicine patch instructions
needs fixingOne pain relief patch was being rotated between fewer sites than the manufacturer's guidance recommended. The manager agreed to take action.
“This was not in line with manufacturers guidance to ensure the patch was working as intended.” from the report
- 01How are falls now reviewed, including footwear, lighting and other environmental causes?
- 02How do you check that audits identify all safety risks in the building?
- 03How is the pain relief patch being rotated now, and how is this recorded?
- 04What drinks and snacks can people choose from, and how can someone get one independently or with suitable support?
- 05How will you make sure the recent improvements continue and do not slip back?
This was an unannounced follow-up inspection covering all five key questions and checking progress after the previous inadequate rating and regulatory breaches. This explanation was written from the published report of 1 May 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Poplars Care Home
4 rated inspections over 5 years: the service has held its Good rating throughout.
- July 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2020Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- April 2020Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Registered with the Care Quality Commission on 30 May 2014.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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