Inspection on 05/11/08 for 34 Porthill Bank

This inspection was carried out on 5th November 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Polesworth Group 68 Long Street

10 Whitfield Avenue

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

CARE HOME ADULTS 18-65 34 Porthill Bank 34 Porthill Bank Newcastle Staffordshire ST5 0AA Lead Inspector Peter Dawson Unannounced Inspection 5th November 2008 09:00 34 Porthill Bank DS0000071639.V372978.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 34 Porthill Bank DS0000071639.V372978.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. 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 34 Porthill Bank Address 34 Porthill Bank Newcastle Staffordshire ST5 0AA 01782 612223 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) www.caretech-uk.com CareTech Community Services Ltd Mr Ian Gibbons Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning Disabilities (LD) 6 The maximum number of service users to be accommodated is 6 Date of last inspection New Service recently registered. Brief Description of the Service: The home provides support and accommodation for up to 6 young adults who have a form of learning disability and complex needs that may include challenging behaviours and/or mental health needs. The service was established for young people 18 years leaving care from children’s homes but requiring ongoing residential support to meet their needs. 34 Porthill Bank provides a good standard environment for 6 young people all having single bedrooms with en-suite shower facilities. The building has been extensively renovated at considerable cost, is spacious, comfortable and furnished to a high standard. Accommodation is on 3 floors with shaft lift access to the first floor. The home is located on the edge of a residential area giving easy access by road and public transport to Newcastle under Lyme and Stoke on Trent. Staff have considerable experience in providing a specialist service to young people and there is a high staffing ratio to ensure the complex needs of the young people are met adequately and safely. The weekly fees for people at Porthill Bank are £1800 - £2900 34 Porthill Bank DS0000071639.V372978.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 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced Key Inspection was carried out by one inspector on one day from 08:30 - 17:00. This is the first inspection following registration of the service earlier in 2008. An Annual Quality Assurance Assessment (AQAA) was sent to us prior to the inspection by the Registered Manager. This is a legal requirement and some information from the assessment is included in this report. The Registered Manager was on sick leave at the time of the inspection. The Acting Manager and the Business Development Manager were present and provided helpful information about the service. There was an inspection of the environment and records relating to the inspection process that included: care planning information, staffing records and rota’s, medication records and other records relevant to the inspection process. All young people were seen and the majority spoken with individually and together. All were admitted to the service recently and spoke enthusiastically about their new home, the good facilities and their plans for the future. No negative comments were made and good engagement was observed between the young people and staff on duty. What the service does well: The service is provided for up to 6 young people leaving local authority care at 18 years but still requiring considerable support in progressing their lives to adulthood. The physical environment has been adapted to provide a comfortable, homely setting with good quality furniture, fittings and equipment. The transition from children’s homes to this adult care home have been handled extremely well. There was a transition plan and period with the young people involved in and being prepared for the move to an adult care home. They have been involved in the planning/refurbishment of the building and the choice of furniture, equipment and facilities. Staff have been transferred from the previous children’s settings providing much needed continuity for this group of young people with complex needs. 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 6 Some staff may return to the children’s services. Some young people may progress to supported living in the community. Good engagement was observed between all staff and the young people. Excellent responses were noted from staff in relation to the repetitive behaviour of some young people. All bedrooms are for single use with good facilities including en-suite rooms with walk-in showers. Bedrooms are personalised reflecting the individual needs and preferences of young people. 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. 34 Porthill Bank DS0000071639.V372978.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 34 Porthill Bank DS0000071639.V372978.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): Standards 1 – 4 were inspected on this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The transitional arrangements for this group of young people moving to this new service have been exceptional – ensuring that their needs and interests will be met with continuity of support from staff who have come with them. EVIDENCE: This home was registered to operate with up to 4 young people from March 2008 and the registration later increased to 6 people from July 2008. It was established to provide accommodation for young adults 18 years and over leaving care from children’s homes settings in the neighbourhood, in fact the building was acquired to provide such accommodation in close proximity to the existing children’s homes. The advantage has been that young people and their families have been involved in the planning and creation of the building specifically as their future home. There are currently six young people who have taken up residence from June this year with the added advantage that they knew each other, lived previously together and made choices about living in their new home. There 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 9 has been an excellent transitional period of introduction, preparation and support in the move to the new home, staff from the children’s service being transferred to the new service and providing necessary continuity for this group of young people with complex needs and inherent required high staffing levels. There is a statement of purpose and service users guide that was prepared and approved for the new registration. There are additional booklets, many in pictorial form, to help people gain knowledge of access to services and the rights and options available to them. The service aims to provide a pictorial copy of the service users guide in the near future 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 10 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): Standards 6 9 were inspected on this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual plans are reviewed regularly. The young people make decisions and are supported to take considered risks to promote an independent lifestyle. EVIDENCE: Care planning information for 2 people was sampled. generally good and comprehensive. Information was All have Person Centred Plans (PCP’s). Information including personal details, previous history, family and friendships are included with preferred lifestyles, choices and future plans. Young people complete plans with support from key workers, part of the record is pictorial and the young person signs the plan. Additional information is provided from assessments and previous history. All 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 11 have brought their personal information from the former children’s services and this has been updated and extended. Behavioural Support Plans have also been updated and contain the necessary information to respond positively and effectively to behaviours presented. Risk assessments are in place covering all aspects of daily living both inside and outside the home. Six monthly reviews of care are planned – the home has been open only 4 months and a decision made to review care and placement after 3 months this has commenced. Daily recording for each person is in place with a summary of care provided for each of the three staff shifts. These records were informative and detailed and summarised well the support provided to people. There were discrepancies in some areas of recording an example was a person assessed as short-sighted and “should wear glasses when watching TV”. This was not done, his glasses were at home and there was doubt about the need for him to wear them. It is recommended that a further optical test should be arranged to clarify this matter. If glasses should be worn as stated a duplicate pair may be needed (he goes home each weekend). A person risk assessed as not able to use the training kitchen alone managed to produce a screwdriver from the main kitchen (no access for anyone without staff present). It is important that tools and other potentially harmful items are locked away to ensure the safety of young people at all times. All staff have had training in Non Violent Crisis Intervention (NCVI) from an approved trainer within the Company (CareTech) and the Manager has recently also been approved as a trainer. The majority of young people present behaviours that challenge but records showed that there had not been any incidents requiring physical intervention since the home was established. This is a positive achievement, particularly considering all the changes the young people have had to deal with. Staff provide people with the support they need to make decisions about their lives. Many have regular home visits and contacts, all have the services of an Independent Advocate from Assist who have been helpful in making major decisions about moving into the home. Many families are actively involved and support people, where there is less family support the Advocacy Service is readily available. Participation in the day to day running of the home is ensured by weekly 1:1 talk time for each person with a key worker, monthly residents meetings, menu planning meetings and the daily engagement with staff. Young people have made choices about colour schemes, purchase of furniture and recently decided they would like the first floor lounge to become a gym – the equipment is on order. They also said that they had decided that they would 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 12 like the detached garage area to be converted into a games room with “bar serving non-alcoholic drinks” – this has been taken seriously and estimates are in the process of being sought. 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 13 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): Standards 11 - 16 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The young people are provided with access to educational, leisure and community facilities, which ensure social inclusion is part of extending and maximising their individual potential and quality of life. EVIDENCE: All six people have recently been admitted being of transition age and moving on from children’s to adult services and brought with them staff who know their chosen lifestyles. The transition has been managed well. Five people are attending Colleges at Shelton and Newcastle full time or 4 days per week. The other person has missed the deadline for college registration and promised a place from the next term, meanwhile has a planned daily 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 14 activity programme. One person attending college needs 2:1 support and therefore supported by a member of staff whilst there. People enjoy a varied range of activities both in the home and the local community. Activity programmes are planned with the young person to meet individual choices and needs. There is opportunity to experience new activities. Youth and sports clubs and community social clubs are examples of this. People have access to gym, library membership, splash swimming pool, Special Olympics, public houses, shops, cinema, bowling etc. This was evidenced in the records seen. Contacts with family and friends are promoted as an integral part of care. Three people regularly go home and stay overnight, others have less or supervised contacts with families and others. Friends are invited to the home, one young person brings a friend home for tea and they spend the evening together. Opportunities for personal development are further promoted inside the home. There is a training kitchen where people can make drinks, snacks and prepare basic meals. The main kitchen area is access by people only with staff presence. People are involved in meal planning, preparation, cooking, serving etc. The usual simple domestic tasks are carried out with staff support as part of maximising social skills. 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 15 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): Standards 18 – 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Urgent review of the system of medication in the home is required to ensure safety of the young people present. Other aspects of healthcare provision are good. EVIDENCE: Support in personal care is not required to meet physical needs - only oversight, prompting and monitoring person hygiene are needed. This is given sensitively and privately by a named carer identified on each shift that the young person can seek support from. Each young person is supported to complete a ‘My Health Action Plan’, these outline diagnosed healthcare needs and the actions/plans necessary to 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 16 promote future healthcare. These are pictorial for easy discussion/use and signed by the young person. Records, including risk assessments, provide information about diagnosed conditions and the actions required to meet healthcare needs. The AQAA (Annual Quality Assurance Assessment) provided by the service stated that there is, “A regular system of attending healthcare checks, including Dentist, Optician, Psychiatrist etc”. The involvement of external professionals since opening have included: GP, Psychology, Psychiatry, Occupational Therapy, Social Workers and Advocates. Optical assessment is required in relation to a person mentioned earlier in this report. Most people have been admitted to the service in the past 3-4 months and records showed that healthcare planning and support is positive. Records from the previous Children’s setting have been transferred to Porthill and together with the transfer of staff who had previous knowledge and experience in providing care for this group are also positive additions. All young people have a diagnosis of autism and challenging behaviours. Additionally some have mental health needs and epilepsy care. Specialist external support is available to meet the complex needs of the group with immediate referrals where there are serious concerns. Health professionals have continued with the care of successful strategies implemented in children services prior to the transition to Porthill. Individual needs are defined in Person Care Plans, 24hour Plans, Behaviour Support Plans and Activity Plans. Prior to this inspection the GP expressed concerns about the medication system in the home via the PCT. These were based upon regular changes in prescription and possible duplication of medication. Concerns were further confirmed when the Registered Manager visited the surgery prior to the inspection expressing concerns about incorrect MAR sheets (Medication Administration Records) which did not match the prescribed medication. Information was given from the surgery concerning previous prescriptions, letters from Consultants etc. The Manager was attempting to clarify all medication prescribed and check this with medication in the home. The GP felt the Managers visit was positive reassuring the practice about concerns they had had. Inspection of the medication system indicated there were 2 systems of medication administration in place – MDS (Blister packs) and bottles. Medication was being changed from the blister packs to bottles as this system was considered satisfactory. There was confusion about the system – on checking a missing signature on a MAR sheet a bottle of 9 tablets was present and also a blister pack with the same medication with some tablets remaining but not been followed in day order – it was impossible to ascertain whether the medication had been administered or whether it was supposed to be 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 17 administered from the bottle or blister pack. Managers present during the inspection were also unaware that there were 2 systems in place and whether medication should be administered from bottles or blister packs. It was noted that 3 packs of Diazepam prescribed PRN (as required) prescribed on the same date for the same person (and unused) were present in the Controlled Drugs cabinet. This is an indication of over-stocking of medication. An immediate requirement was made for the service to urgently review medication with the GP and Pharmacy and ensure the safe recording, handling, safekeeping and administration of medicines in the home. This will ensure the safety of the people in the service. A safe system of medication must be introduced, which includes ordering, storage and administration so that there is no doubt that people are receiving the medication they require. The Registered Manager, on sick leave at the time of this inspection, carried out a recent investigation in relation to errors in the system. Unfortunately his report was not available in the home on the day of this inspection and a Manager present undertook to forward this to us following the inspection. Following the inspection, information was received from the Area Manager stating that due to discrepancies the pharmacist was asked to change the system from blister packs to bottles. This had not been conveyed to the Managers present during the inspection and further adds to the confusion. This is not acceptable and presents potential risks to people in the home. 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 18 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): Standards 22 & 23 were inspected on this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A comprehensive and robust complaints procedure ensures people know how to make a complaint. Some further staff training is needed to ensure the protection of people from abuse. EVIDENCE: There is a complaints procedure available in the reception area of the home for visitors. A pictorial version of the procedure was available for the young people also. No complaints have been received by the home since it opened 5 months ago and none received by us. 1:1 talk-time with key workers provides the opportunity for people to raise any areas of concern. There is a Safeguarding Adults policy and a copy of the Safeguarding procedures of the Local Authority. Some staff completed training relating to Safeguarding, some have not - and nominations reportedly have been made for training. It is important that all staff have training in recognising and responding to perceived or actual abuse. 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 19 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 20 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): Standards 24 – 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment provides a spacious, comfortable, well-furnished homely setting for six young people. EVIDENCE: This is a newly registered home meeting the National Minimum Standards for registration. It was commissioned and established specifically for this group of young people previously in local children’s homes who required at 18 years a local, suitable home to meet their needs. The building has been extensively renovated at considerable cost, to provide a spacious, comfortable, well-furnished and equipped home for up to 6 young 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 21 people. They have been involved in choices about facilities, colour, furnishings – their preferences and choices sought in establishing their new home. Thee are 2 lounges on the ground floor, where the reception area is located, there is a separate dining area, a main kitchen and training kitchen a laundry and office accommodation on this floor. On the first floor there is a smaller lounge equipped with CD player and Playstation. A smaller room is awaiting gym equipment – a request/suggestion made by the young people. There are 2 single bedrooms and 2 flats on the first floor, both have en-suite facilities including walk-in shower, the flats also have a lounge area and used for people who may ultimately be supported in the community. There are 2 single bedrooms on the second floor, both with en-suite facilities and walk-in shower rooms, to be used for less dependent people as part of the Registration agreement. The communal lounge areas provide a choice of venue and occupation for people - examples given were from disco’s to quiet areas. The main lounge is a combination of 2 rooms allowing space for whole-group activity or just TV viewing together. All have personal TV’s in their bedrooms. The home is extremely well presented throughout. Furniture, fittings and equipment is to a high standard, providing a comfortable homely setting and fit for purpose. Plans to convert the separate garage into a games room with bar has been requested by the young people and is presently being costed. Bedrooms seen were bright and well furnished with good en-suite facilities. All were personalised reflecting the individuality of each person. Standards of hygiene throughout were good. There are regular Health and Safety and fire checks of the building. Daily cleaning schedules carried out by staff, involving the young people where appropriate as part of skill development. It was reported in the AQAA that regular monthly visits are made by the Area Manager under Regulation 26 of The Care Homes Regulations, but the required reports of the visits were not in the home. 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 22 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): Standards 31 – 36 were inspected on this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Experienced and competent staff ensure the complex needs of this group of young people are adequately met. EVIDENCE: Staff roles are clearly defined. Most staff have previous knowledge/experience of providing care for this group of young people from a previous children’s setting. This has provided the desirable continuity of care, which together with the well-planned transition has allowed a smooth move to the new service. This is reflected in the anticipation of major settling or behaviour issues that have not occurred. Staff felt that the increased space at Porthill has also helped in allowing people more personal space and reducing tensions. This has been successful. Staff transferred to the service have considerable experience and training. Records showed that statutory training has been provided within required 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 23 timescales, with inductions for all to the new service. One area of shortfall is training in Safeguarding, mentioned previously, which is important for all staff in this adult setting. Staffing levels were discussed and evidence from staffing rotas. There are 5-6 staff on duty throughout the day – 5 people have allocated 1:1 staffing as part of their assessment and contractual arrangements. This works well, with staff allocated to each person daily. The number does reduce when people attend college courses, although one person needs a member of staff present whilst there. There are 2 waking night staff on duty. Three had been proposed in the original registration application but people have settled well into the new service and there are no significant demands during the night. Two is an adequate number for the current group and their dependency levels. A total number of 644 staffing hours were provided in the week prior to the inspection. This is good and meets the needs of the people in the service. There is no staff-training matrix for easy reference and the service intend to establish this. Recruitment procedures were inspected. A sample of two staff files were seen. Recruitment records are generally held by the Company’s Human Resource section with a pro-forma on each file to indicate all checks, references and documents had been obtained. In one record there was no pro-forma but records such as application forms, interview records and some copy documents seen. These are usually only in the HR records section but had been obtained by the Manager for reference. These copy documents were later found in the records. One file did not have a pro-forma attached and a telephone call to HR personnel provided confirmation (not seen) of most documents, although it was finally established that there was no photograph of the person as required and no ID badge. This is potentially confusing. Pro-forma use has been agreed with the service and these should be available in all staff files. It is also important that all documents required under Schedule 2 of the Care Home Regulations are obtained. Copies of documents such as application forms and references would be helpful to the service if provided in the home. There is no confidentiality/data protection issue in the storage of this information that is secure and accessible only by the manager. Training records (also secure) were seen and evidenced regular supervision. 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 24 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): Standards 37 and 39-43 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Some aspects of management could be strengthened to ensure the safety and welfare of those using the service. EVIDENCE: A Registered Manager was approved and has been operating the service since registration. He has had periods of sick leave and was not working at the time of this inspection, so it was not possible to meet him. 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 25 An Acting Manager was brought into the service in the week prior to this inspection. The inspection was carried out with her and also the Business Development Manager who are providing management cover to the home in the absence of the Registered Manager. Both provided helpful information and detail about the service. In the absence of the Registered Manager it was not possible to make a judgement about the ethos, leadership and management approach in the home. Clearly a lot of good work has been invested in planning and establishing the home with a good transition plan to ensure people settled quickly and well – evidence of this was seen. Line Management is provided by the Area Manager who is reported to visit monthly. Unfortunately there were no records of the visits and the providers are reminded that under Regulation 26 visits must by monthly, unannounced and a report of the findings of the visit must be provided to the Registered Manager. There are policies and procedures provided for the service by CareTech (Providers) covering the required aspects of operation to inform staff and ensure standards. Feedback about the service is obtained in 1:1 talk time by key-workers from all young people. Reviews and feedback at residents’ meetings are a source of feedback. Monthly meetings with people take place but only the minutes of the October meeting were available. Feedback from staff is obtained from staff meetings and supervision. The providers have an internal Quality Assurance section that includes an annual audit and survey for people using the service. Recent registration means that these have not yet been completed but will provide future feedback. It is also important to consider feedback from relatives/visitors and external stakeholders including GP and other healthcare professionals who are in contact with the service. 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 26 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 3 2 3 3 3 4 4 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x X 2 3 3 3 2 2 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? 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 YA20 Regulation 13(2) Requirement An urgent review of medication in the home is required to ensure the safe administration of medication to people using the service. Timescale for action 05/11/08 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 2 3 Refer to Standard YA23 YA20 YA39 Good Practice Recommendations All staff must received training in Safeguarding and the protection of vulnerable adults. A copy of the recent investigation report in relation to medication in the home should be sent to CSCI Visits under Regulation 26 must be recorded, a copy provided to the manager and left in the home. 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands 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 34 Porthill Bank DS0000071639.V372978.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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