CQC report explained · a residential care home
What the CQC found at The Poplars
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found environmental risks from flooring, lighting, stairs, hot surfaces and an unlocked trap door. They also found unsafe moving and handling practice, although medicines, safeguarding and much of the infection control practice were satisfactory.
- Effective?
- Good
- This area was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This area was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Well-led?
- Requires improvement
- Quality checks did not identify or deal with the safety problems found. People and staff were not effectively involved in decisions about the environment, and plans to introduce a key worker system were not yet fully in place.
What inspectors found, November 2022
The Poplars was rated Requires Improvement; inspectors found risks in the building, unsafe moving practices and weak management checks.
This was an unannounced focused inspection on 7 November 2022. Inspectors looked only at Safe and Well-led. They spoke with 10 people, one relative and seven staff, and reviewed care plans, medicines records and management checks.
The home was not always safe. Inspectors found fall and burn risks in the building, including poor lighting, unsuitable stair barriers, exposed hot surfaces and an unlocked trap door. They also found that one moving and handling technique could injure someone.
There were enough staff during the visit, medicines were given safely and staff understood safeguarding and infection control. However, people said staff interactions were rushed and task-focused, and they did not feel properly involved in decisions about the home.
The overall rating remained Requires Improvement, as did Safe and Well-led. The other three areas were not inspected and their previous ratings were used to calculate the overall rating.
Medicines
People received their medicines as prescribed and on time. Staff were trained and assessed as competent before giving medicines.
“People received their medicines as prescribed and when directed.” from the report
Safeguarding
Staff had training to recognise abuse and understood how to report concerns. Inspectors found people were protected from abuse and ill-treatment.
“People were protected from the risk of abuse and ill treatment as staff members had received training on how to recognise and respond to concerns.” from the report
Infection control training
Staff understood infection risks and used protective equipment appropriately. The home had updated infection control training in response to COVID-19.
“Staff members had access to personal protection equipment which they used appropriately when supporting people.” from the report
Local healthcare links
The management team maintained links with local services, including GP practices, which people benefited from.
“The management team had established and maintained good links with the local communities within which people lived.” from the report
Unsafe environment
seriousThe building had several hazards that could lead to falls, burns or injuries. Inspectors found that some immediate risks were addressed during or after the visit, but the problems led to a breach.
“These issues created an increased risk of falls to people especially those living with dementia or those with a visual impairment.” from the report
Moving and handling
seriousA person described being helped to stand using an unsafe technique. Staff confirmed this was sometimes used while waiting for equipment training.
“One person described how staff supported them to stand using an unsafe lifting technique putting them at the risk of injury.” from the report
Weak quality checks
seriousThe home's monitoring systems did not identify or reduce the risks found by inspectors. This led to a breach of the good governance regulation.
“The provider had quality monitoring systems in place, but these were not effective in identifying and mitigating the issues we found at this inspection.” from the report
People not listened to
needs fixingPeople said their interactions with staff were rushed and that their views were not valued. They were not effectively consulted about changes to the building or aspects of their care.
“People did not feel consulted, or their opinions valued.” from the report
Infection risks in the building
needs fixingInspectors found dirty or rusty items and blocked access to handwashing facilities. The layout and condition of parts of the building made effective cleaning harder.
“We saw discoloration on lighting pull cords, rust on some pieces of equipment which hampered effective cleaning” from the report
- 01What has been completed to make the flooring, lighting, stairs, stair gate, trap door, radiators and hot water pipes safe?
- 02How do you now check that staff use safe moving and handling techniques, and has the required equipment and training been provided?
- 03How are people consulted before changes are made to communal areas or other parts of the home?
- 04Has the key worker system now been fully introduced, and how does it help people make choices about their care?
- 05How do your quality checks identify risks that inspectors previously found, and can we see the improvement action plan?
This was an unannounced focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection and were used to calculate the overall rating. This explanation was written from the published report of 29 November 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, September 2019
Rated Requires Improvement; inspectors found kind care, but medicines systems and leadership needed strengthening.
This was an unannounced inspection on 23 July 2019. Inspectors spoke with people living at the home, relatives, friends, staff and health professionals. They observed care and checked care, medicines, recruitment and management records.
People were generally treated kindly and respectfully. Inspectors found good care in the effective, caring and responsive areas. People said they felt safe, liked the food, received healthcare support and could take part in activities.
The main problems were with medicines records and checks. Some medicine administration records were missing signatures, stock levels were not always recorded, and one person had not received prescribed medicines the previous day. The home also lacked a planned way to set staffing levels as people's needs changed.
The overall rating was Requires Improvement. Safe and well-led were rated Requires Improvement, while effective, caring and responsive were rated Good. The previous overall rating was Good, published on 21 January 2017.
Kind and respectful staff
People and relatives described staff as caring. Inspectors saw staff speaking about people with respect and empathy.
“They are kind and respectful staff, they are all very lovely” from the report
Food and healthcare
People had choices of food and drink, and the home worked with health professionals to provide support.
“People had a choice of food and drink and we observed one person telling a carer who was supporting them with their meal the food, "Tastes very nice.” from the report
Activities and relationships
People were supported to join activities in the home, including quizzes, bingo and a weekly church service.
“There was a weekly church service provided at the home, which we saw was well attended by people.” from the report
Respect for independence
Staff encouraged people to remain independent and did not rush them. Inspectors found that privacy and dignity were respected.
“We encourage independence even if it is time consuming. We don't rush the residents.” from the report
Medicines records and missed dose
seriousSome medicine records lacked signatures and stock levels were not always recorded. One person had not received prescribed medicines the day before the inspection, creating a risk of harm.
“We found one person had not received their prescribed medicines from the day before.” from the report
Staffing planning
needs fixingThere were enough staff during the inspection, but the home did not have a systematic method for deciding staffing levels from people's needs. This could become a problem if needs changed.
“There was no systematic approach in place to establish staffing levels based on people's needs.” from the report
Care review records
minorThe home asked people for their views, but records did not show how many people had been included in care reviews.
“We saw that reviews of people's needs were held but it was not evident how many people had been included in these reviews.” from the report
Personalised care guidance
needs fixingSome care plans did not give staff enough personalised guidance, including information about triggers and distraction techniques for behaviour that challenged.
“However, some care plans lacked guidance for staff which was personalised to that person.” from the report
- 01What changes have been made to medicine administration records, stock checks and missed-dose procedures since the inspection?
- 02How do you now calculate staffing levels when people's needs change?
- 03How are care reviews recorded, and how do you show that each person and their relatives have been consulted?
- 04How have care plans been updated to include personalised guidance about behaviour, triggers and distraction techniques?
- 05What checks are now in place to make sure management systems identify medicine and staffing risks promptly?
This was an unannounced planned inspection that covered all five CQC questions, with the previous overall rating of Good reviewed because of the home's earlier rating. This explanation was written from the published report of 3 September 2019 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 The Poplars
3 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- November 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- January 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 17 January 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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