CQC report explained · a residential care home
What the CQC found at Poplars
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found risk assessments, suitable staffing, safe recruitment and safe medicines arrangements. The home was clean and odour free.
- Effective?
- Good
- Staff had induction, training and supervision. People received support with food, drinks and healthcare, although some capacity and best-interest records were not yet complete.
- Caring?
- Good
- Staff were kind and knew people well. They respected privacy, dignity, choices and independence.
- Responsive?
- Good
- Care records described people's needs, communication and preferences. People had activities and family contact, although one relative raised a concern about losing access to a particular activity.
- Well-led?
- Good
- The home had regular audits, meetings and a quality improvement plan. Managers and staff showed an open attitude to learning and improving care.
What inspectors found, March 2020
Poplars is rated Good; inspectors found safe, kind and personalised care, with some records and improvement actions still to complete.
This was an unannounced inspection on 11 February 2020. One inspector reviewed care, medicines, recruitment and management records. They also spoke with five staff, five relatives of four people, and a senior manager.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines arrangements, clean surroundings, kind staff and person-centred care. People were supported to make choices, stay independent, keep in touch with family and take part in activities.
There were some matters still being addressed. Capacity and best-interest records were incomplete for some aspects of care. An infection control audit had scored 85%, with action under way. One relative was concerned about access to a favourite activity. The overall rating was unchanged from the previous Good rating published in July 2017.
Safe medicines
Medicines were stored and given safely. Only trained and assessed staff administered them.
“Medicines were only administered by staff who had received appropriate training and were assessed as competent to do so.” from the report
Choice and independence
People were supported to make decisions and do as much as possible for themselves.
“People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests” from the report
Personalised care
Care records described individual needs, communication methods, preferences and support arrangements.
“Care records were reviewed and updated to ensure they were reflective of people's current care and support needs.” from the report
Quality monitoring
Audits and a quality improvement plan were used to identify and track improvements.
“Findings from audits were recorded on a quality improvement plan.” from the report
Incomplete capacity records
needs fixingSome capacity assessments and best-interest decisions had not been completed for parts of people's care. Managers had identified this and said they planned to correct it within the following weeks.
“We noted capacity assessments and best interest decisions had not been completed for some aspects of people's care.” from the report
Infection control actions
needs fixingA local authority infection control audit scored 85%. The report says action was already being taken to address the shortfalls.
“The home had recently had an infection prevention and control audit by the local authority. The home had scored 85%.” from the report
Access to a favourite activity
minorOne relative was concerned that their family member could no longer take part in an activity they enjoyed. A senior manager said this would be followed up.
“One of the relatives we spoke with was concerned their relative no longer had access to a particular activity they enjoyed.” from the report
- 01Have all the outstanding capacity assessments and best-interest decisions now been completed?
- 02What actions were taken after the infection prevention and control audit scored 85%?
- 03How do you make sure each person keeps access to activities they enjoy?
- 04How are actions on the quality improvement plan checked and signed off?
- 05How are relatives involved when care plans are reviewed or concerns are raised?
This was an unannounced inspection covering the home, the care provided and all five CQC questions; the previous rating was from 2017. This explanation was written from the published report of 12 March 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.
What inspectors found, July 2017
Rated Good; inspectors found safe, kind and personalised care, with improvements made to staff training since the previous inspection.
Inspectors visited on 24 and 26 May 2017. The first visit was unannounced and the second was announced. They spoke with people, relatives, staff and managers. They also observed care and checked care records, recruitment files, training records, maintenance records and audits.
The home supported 12 young adults with profound and complex needs. Inspectors found enough staff to meet people's assessed needs, safe medicines arrangements, detailed risk assessments and robust recruitment checks. Staff had specialist training and understood how to support people who could not make some decisions for themselves.
People were treated with kindness and respect. Their communication methods, preferences, health needs, activities and relationships were recorded in personalised plans. The home was judged Good in all five areas: Safe, Effective, Caring, Responsive and Well-led.
At the previous inspection in January 2015, the provider was not meeting requirements about staff training and support. Inspectors found that these improvements had been made by this inspection.
Personalised care
Care plans described people's routines, preferences, communication and equipment in detail. Relatives were involved in planning and reviews.
“Support plans were very detailed and person-centred and included photographs of the equipment people used.” from the report
Kind and respectful staff
Inspectors saw staff communicating patiently and respectfully. People were supported to make choices and remain as independent as possible.
“Staff worked in a supportive way with people and we saw examples of kind and caring interactions that were respectful of people's rights and needs.” from the report
Staff training
Staff received a thorough induction, supervision and specialist training linked to people's needs. This addressed the shortfall found at the previous inspection.
“We found staff were provided with training and support to ensure they were able to meet people's needs effectively.” from the report
Safe medicines
Medicines were checked, recorded and administered by trained staff. Inspectors found accurate records and regular stock checks.
“This demonstrated the home had good medicines governance in place.” from the report
Activities and relationships
People were supported to take part in activities inside and outside the home, use day services and keep in contact with family.
“People were supported to participate in activities both inside and outside the home.” from the report
Quality monitoring
Managers used regular audits, feedback and meetings to check the quality and safety of the service. Actions had named responsibilities and deadlines.
“There was evidence of internal daily, weekly and monthly quality audits, and actions identified showed who was responsible and by which date.” from the report
Vacancies and agency staff
needs fixingThere were staff vacancies and agency staff were still being used regularly when inspectors visited. Inspectors found enough staff, but families may want to ask about continuity and recruitment.
“The registered manager said there were some staff vacancies, which had been recruited to and were awaiting pre-employment checks, so agency staff were still regularly being used.” from the report
Medicines room temperature
minorThe medicines room had occasionally been above the recommended temperature. A fan was used, and air conditioning was installed shortly after the inspection.
“The temperature of the medicines room had occasionally gone over the recommended temperature and a fan had been used to reduce this.” from the report
- 01How many permanent staff are now in post, and how often are agency staff used?
- 02How do you make sure new or agency staff understand each person's detailed communication methods, routines and risk assessments?
- 03Has the medicines room remained within the recommended temperature since the air conditioning was installed?
- 04How will my relative and our family be involved in care plan reviews and decisions about activities, health care and best interests?
- 05How are complaints, feedback and audit actions recorded and followed up?
This was a comprehensive inspection of the overall quality of the home, covering all five CQC questions and checking improvements since the January 2015 inspection. This explanation was written from the published report of 7 July 2017 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
3 rated inspections over 5 years: the service has held its Good rating throughout.
- March 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- May 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- December 2011
Registered with the Care Quality Commission on 14 December 2011.
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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