CARE HOMES FOR OLDER PEOPLE
Portcullis House The Embankment Langport Somerset TA10 9RZ Lead Inspector
Ms Sue Hale Unannounced Inspection 19th July 2006 09:30 X10015.doc Version 1.40 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 Portcullis House DS0000016076.V305080.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 Older People. 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. Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Portcullis House Address The Embankment Langport Somerset TA10 9RZ 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) 01458 250800 01458 253772 Somerset Care Limited Mrs Christine Carol Dowdell Care Home 40 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. REGISTERED FOR 40 PERSONS IN CATEGORIES OP AND DE (E) One named service user aged under 65 years to be admitted to the home 2nd November 2005 Date of last inspection Brief Description of the Service: Portcullis House is a purpose built residential home, located within a residential area of Langport. There is a range of communal areas at the home. A passenger lift, assisted bathrooms and a call system are provided. The home is set in pleasant gardens that are accessible to service users. The home is registered with the Commission for Social Care Inspection to provide care for up to 40 service users over the age of 65 years. Within the home there is a Specialist Residential Care (SRC) unit called Rose Garden that provides additional care and support to service users who have a dementia. Day care is also offered at the home, including services for those who have specialist mental health needs. The Registered Manager is Mrs Christine Dowdell, and the Registered Provider home is Somerset Care Limited. Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced in the place over the course of one day in July 2006. It was undertaken by two inspectors. The inspectors looked at a selection of resident and staff files, policies and procedures, and other records relating to the running of the home. A tour of the building was undertaken and care practice in the routines of the home observed. The Inspector spoke to the manager, some members of staff, some residents and visitors to the home. Surveys were sent out to residents, relatives/representatives and health and medical professionals. Two comment cards were received from healthcare professionals both of whom indicated that the home communicated clearly and works in partnership with community professionals. Three surveys were received from residents and whilst the comments made by residents on the day of inspection were generally positive, amongst the anonymous respondents one commented that staff do not always listen to them, two felt that staff are ‘usually’ available when they needed them and one commented that medical support was available only ‘sometimes’. Relatives on behalf of residents returned three surveys. Whilst they were generally positive with one respondent noting that they were very satisfied with the level of care their relative received at the home, another respondent noted concerns that staff were very busy and that sometimes their relatives care ‘was sparse’. The current fee levels are between £361 to £436 per week. What the service does well:
Residents are only admitted to the home following a meeting with the manager or her deputy and the completion of the pre admission assessment to ensure that the home can meet their social, health and care needs. Prospective residents are given the opportunity to visit the home and spend time there before they make a decision about moving in. Each resident is provided with a clear statement of terms and conditions that sets out the terms and conditions of residency. All residents have a plan of care detailing their care, social and health needs and how staff should meet those needs. Residents have access to health care services that meet their assessed needs within the home and the local
Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 Page 6 community. Residents are treated with respect and their dignity maintained by staff. The home works to an efficient medication supported by procedures and practice guidance. The routines of the home are planned around residents and needs and wishes. The residents are encouraged to personalise their rooms. The home takes residents opinions seriously and makes changes where possible. Appropriate activities are available throughout the home. Residents are able to continue with their individual religious observance and have opportunities to talk privately to a minister. The home ensures that residents and their relatives have access to advocacy services. The residents are satisfied with the meals served the home. Visitors to the home feel welcome and know they can visit the home at any time. The home has policies and procedures in place in relation to complaints and protection of vulnerable adults. Staff receive training in adult protection. The home has a well-maintained environment, which provides aids and equipment to meet the care needs of residents. The shared areas provide a choice of communal space with opportunities to meet relives and friends in privacy or in their own room Residents have confidence in the staff that cares for them. Management encourage staff members to undertake training and obtain qualifications beyond basic requirements and recognises the benefits of a skilled workforce. The home was adequately staffed on the day of the inspection. The manager has the required qualifications, skills and experience and is competent to run the home. Residents and staff are kept informed and involved in the running of the home. Staff are provided with training and have the skills and experience to meet the needs of residents. One resident spoken to said that she liked that staff and that ‘they look after me’. All the residents spoken to were very satisfied with the care they receive at the home. The home has clear health and safety policies and regular checks take place to ensure that the home is a safe environment. Residents are able to take responsibility for their own finances but if they are not able to do so robust systems are in place to safeguard their financial interests. What has improved since the last inspection?
Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 Page 7 The home has addressed several requirements made in the last report including, definitions on MAR sheets are now used, hand transcribed entries are confirmed by a second staff signature and an opening and expiry date is recorded on all creams and ointments. The toilets near to the lounge have been decorated and a curtain fitted in the room identified in Rose Garden and tablets of soap, combs and nailbrushes are no longer kept in communal bathrooms. Portable appliances had been tested and hazardous substances stored securely. The home has also addressed the outstanding recommendation that emergency lighting should be tested monthly. What they could do better:
The registered manager should ensure that all assessment and care planning documentation is fully completed, dated & signed. Assessments should be updated as necessary to reflect changing needs and give staff current information about residents care and health needs. The registered manager should ensure that all care plans are reviewed monthly with residents and that they are asked to sign their agreement to the plan if they are able to do so. All residents must have a moving and handling risk assessment undertaken on admission and updated and reviewed as necessary. All residents should have a nutritional risk assessment undertaken on admission and regularly thereafter as necessary All residents should be offered the opportunity to have a bedside light if they so wish. The laundry must be kept clean and tidy. Serious consideration should be given to installing a keypad system on exterior doors to ensure the safety of residents. The door to the sluice must be kept locked at all times. References must be obtained before new staff starts working at the home to ensure that they are suitable to work with vulnerable people. All staff should be given name badges so that residents know who they are. Experienced members of staff should undertake induction training and support for new staff. Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 Page 8 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. Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 Page 9 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 Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. Standard 6 is not applicable to this service. The quality of this outcome group is good. The home provides a statement of purpose and service user guide that clearly sets out the objectives and philosophy of the service. Prospective residents are given the opportunity to spend time in the home. Admission to the home is not made until an assessment has been undertaken. Each resident is provided with a clear statement of terms and conditions that sets out the terms and conditions of residency. EVIDENCE: The home has a corporate style Statement of Purpose, adjusted to reflect Portcullis House and a service user guide that is given to prospective residents and their families. The documents are informative and clear about the services
Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 Page 11 offered at the home and the homes culture and values. The documents are available in various formats including audiocassette. The inspectors examined the personal files of four residents. The manager or her deputy undertakes preadmission assessments for people moving into the home on a trial basis or for day care to ensure that the home can meet their needs. This assessment was seen on files checked but were not always fully completed, dated and signed. All admissions on a trial basis and are subject to review after six weeks. Residents spoken to confirmed that they were supported and encouraged to visit the home and spend time there before they made the decision to move in. One resident said that ‘staff were very helpful, they came to see me at home before I decided to come here’. The home has a contract of the terms of conditions of residency that meets the national minimum standards. The contract makes clear what is included in the fees and what separate expenses residents are responsible for. Copies of the contract were seen on selected residents files and residents surveyed were aware of the terms and conditions of residency. Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. The quality of this outcome group is adequate. Risk assessments were not undertaken as a matter of course or in some case where necessary, and they were not updated to reflect residents’ current needs. Each resident has a plan of care, but practice of involving residents in the development and review is variable. Residents have access to health care services that meet their assessed needs within the home and the local community. Residents are treated with respect and their dignity maintained by staff. The home works to an efficient medication supported by procedures and practice guidance. EVIDENCE:
Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 Page 13 All residents files checked contained a basic plan of care and instructions for staff on how to meet individuals assessed needs. As stated previously not all documentation was fully completed, dated and signed. Not all files checked had moving and handling risk assessments and of those that did two had not been reviewed and updated since 2005. One resident’s file did not contain a nutritional assessment or pressure sore risk assessment despite evidence in the file that they were doubly incontinent and losing weight. Some care plans and assessment were not up to date and did not reflect current needs. This was also commented on by a visiting healthcare professional that although staff were familiar with individual needs care plans did not always reflect current situations. There was some evidence of monthly and six monthly reviews but this was not consistently carried out on all files checked. On one file checked it was evident that the residents relatives had been involved and it is signed the agreement to the care plan. It was noted on residents’ files and confirmed by a relative that they were supported by staff to access appropriate health and medical care including chiropodist, dentist, and opticians. Residents at risk of pressure sores were referred to the district nurse and any necessary equipment such as cushions and mattresses provided by the home. It was observed throughout the inspection that staff were professional, but friendly and treated residents with respect and that care interventions were undertaken in a way that respected individuals dignity. The staff training programme, policies and value statements in the homes service user guide also make it clear that this is normal practice in home. Staff are provided with medications training. All medications are stored securely. The medications fridge is locked and the temperature monitored on a daily basis. Medication Administration Records include a photograph of the service user. A record had been maintained of all medications entering and leaving the home. Hand transcribed entries had been confirmed by a second staff signature. Variable doses are recorded. When definitions are used it is clearly stated what the abbreviation means. An opening or expiry date is recorded for all prescribed creams. Patient information leaflets are retained and staff work with residents GP’s to arrange medication reviews six monthly. Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. The quality of this outcome group is good. The routines of the home are planned around residents and needs and wishes. The residents are encouraged to personalise their rooms. The home takes residents opinions seriously and makes changes where possible. Appropriate activities are available throughout the home. The home ensures that residents and their relatives have access to advocacy services. The residents are satisfied with the meals served the home. Visitors to the home feel welcome and know they can visit the home at any time. EVIDENCE: The daily routines of the home were seen to be as flexible as possible to meet the needs and choices of residents. Residents spoken to confirmed that they
Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 Page 15 are able to rise and retire at times to suit themselves. They also confirmed that they were able to see their visitors in private if they wished to. Residents’ files contained background information and social histories that included details of individuals’ ethnicity, culture and religious preferences and how the home and staff met these needs on an individual basis. Residents spoken to confirmed that they are able to continue to practise their individual religion and this was seen by the inspectors on the day the visit when the local vicar was visiting the home and conducting a service for several residents and also making it known that she was available to speak privately to individuals if they so wish. Activities were available and tailored to individuals’ preferences and ability. Staff were observed assisting residents to participate in activities and were seen to be supportive and appropriate. One resident was aware of the activities but chose not to participate and they said that staff respected this. The home has planned a summer fete to take place in August and residents and their relatives and friends have been invited along with members of the local community. Meals are prepared on the premises. The menu is displayed in the dining room, and a choice of meals is available each day. The home is able to cater for specialist diets. Staff are aware of residents dietary preferences and needs. Homemade cakes are prepared each day. The main meal is served at midday. Vegetables are placed in serving dishes on each table so that residents may choose which they have. Condiments are available. Residents spoken to were very pleased with the meals served at the home. Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. The quality of this outcome group is adequate. The service has a complaints procedure that generally meets the national minimum standards and regulations. Residents were confident that they could raise complaints or concerns with senior staff. The home has policies and procedures in place to ensure the protection of residents living at the home. EVIDENCE: The home has a corporate complaints policy which gives the timescale within which complaints will be responded to and investigated. The homes leaflet ‘Seeking your Views’ is given to all new residents. The information about complaints in the statement of purpose needs updating and the leaflet ‘Seeking Your Views’ should make clear that complainants are able to contact the Commission for Social Care Inspection at any stage of a complaint. No complaints have been received by CSCI or the home since the last inspection. All residents spoken to during the inspection said they felt confident in raising any concerns or complaints with the manager or senior staff and that they would be addressed and sorted out. Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 Page 17 A visitor to the home was clear that they could talk to the manager or the deputy manager if they had any complaints or concerns. The home has a policy and procedure on the protection of vulnerable adults and this is available to all staff. The information on action to be taken by the manager should a serious allegation be received needs to reflect the advice given in Safeguarding Vulnerable Adults Adult Protection in Somerset Multi Agency Policy and Practice Guidance. Appropriate recruitment checks of undertaken of new staff to ensure the protection of people living at the home. The home has up-to-date policies giving staff advice on how to manage physical and verbal aggression by residents. The homes policies make it clear to staff that they cannot accept gifts from residents and cannot assist with or benefit from residents wills. Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26. The quality of this outcome group is good. The home has a well-maintained environment, which provides aids and equipment to meet the care needs of residents. The shared areas provide a choice of communal space with opportunities to meet relives and friends in privacy or in their own room. EVIDENCE: The home was clean, tidy and free from odours on the day of the inspection. One resident said that ‘staff keep my room clean and tidy’. Residents’ accommodation is provided over two floors. There is a passenger lift, assisted bathroom and call system available to residents. The home has a range of communal areas. There is a large lounge, dining room and conservatory on the ground floor. A separate lounge / dining room is provided
Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 Page 19 for Rose Gardens. There is an additional dining room and lounge on the first floor and further seating areas throughout the home. It was evident by checking one resident’s personal file, talking to the resident concerned and by observation that they were disorientated and at risk of leaving the home unaccompanied. It was noted by the inspectors that the front doors of the home do not have a keypad system to reduce the risk of residents wandering unaccompanied away from the home. In discussion about this the manager agreed that this could present a risk to other residents who are increasingly confused on admission. Service user rooms have been pleasantly decorated. All rooms seen had been individualised to reflect individual tastes and preferences. Not all rooms had a bedside light available. Appropriate adaptations have been provided to meet service users’ needs. Eight residents rooms have en suite facilities. There are communal toilets located throughout the building. Those situated close to the lounge had been redecorated. There is an on-going program of re-decoration and re-furbishment throughout the home. Radiators have been guarded, and window openings restricted on upper floors. Emergency lighting is provided throughout the home, this was tested monthly as recommended in the last report. Hot water outlet temperatures were tested and found to be within appropriate limits. The laundry was not very clean and cobwebs were visible. Alginate bags are used as required. The home has been maintained to a high standard of cleanliness. The home uses latex gloves for staff. Advice in relation to this should be sought from the Health Protection Agency. The home has sluicing facilities, the door to which was unlocked and could have accessed by residents. A visitor to the home stated that when they visited their relatives’ room ‘it is always clean and fresh’. Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. The quality outcome for this group is adequate. Residents have confidence in the staff that cares for them. Management encourage staff members to undertake training and obtain qualifications beyond basic requirements and recognises the benefits of a skilled workforce. Further efforts are needed to ensure recruitment and induction practices improve. EVIDENCE: Duty rotas are maintained. On the day of the inspection the home was fully staffed and able to meet residents needs. The registered manager is also supernumerary to the staff team for part of the week. All residents spoken to were satisfied with the care they receive from the manager and staff. The manager stated that the home always had staff vacancies and were continually trying to recruit new staff. A healthcare professional visiting the home stated that there had been a lot of staff changes in recent months and that the standard of care in Rose Garden had suffered due to this, in particular with no member of the management team taking a lead role in the unit. This has now been rectified and the deputy manager will take this role on. It was stated that additional staff on Rose Garden would probably improve the standard of care and enable more activities and stimulation for residents to be provided.
Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 Page 21 Newly appointed staff receive induction training, and specialist foundation training is also available. However, some staff felt that the induction training was not of sufficient detail to prepare them for their role and would welcome a staff handbook as a ready source of support. Some staff also commented that the induction training was not always undertaken by senior staff but by recently employed staff. The home ensures that staff receive regular updates in fire safety, manual handling and health and safety training. Individual staff training records are maintained. Staff are encouraged to attend further training and are supported in studying for NVQ qualifications in care. Currently 70 of staff is trained to NVQ level 2 or above to ensure that they have the skills and experience to provide a high standard of care. Recruitment files were examined for three recently employed members of staff. The inspectors noted on two files that one of the references has not been obtained before they started work. Other documentation required by the Care Homes Regulations was in place. The inspectors observed that some but not all staff had name badges. Some staff spoken to said that they had not been given name badges and did not have terms and conditions of their employment. A visitor to the home said that the’ staff all appeared kind, patient and caring and were aware of when they were needed by residents’. A survey respondent stated that their relatives care ‘was sometimes sparse as the staff are very busy,’ they went on to comment that their relative ‘receives only one bath a week’. Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. The quality of this outcome group is good. The manager has the required qualifications, skills and experience and is competent to run the home. Residents and staff are kept informed and involved in the running of the home. The home has clear health and safety policies and regular checks take place to ensure that the home is a safe environment. Residents are able to take responsibility for their own finances but if they are not able to do so robust systems are in place to safeguard their financial interests. EVIDENCE:
Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 Page 23 The registered manager is Mrs Christine Dowdell. She has considerable experience of providing care to older people and has obtained the NVQ level 4 qualification. Residents spoken to said that she and the staff team were approachable, and that they would feel able to raise any issues of concern. There is a relaxed atmosphere within the home. The home seeks feedback from residents and their families on an individual basis, and at regular meetings to which all are invited. The home will keep money securely for any residents that wish them to. Two staff signatures support transactions involving service user finances and receipts are obtained. The accident book was available to staff and selected residents personal files were cross-referenced and found to be correctly recorded in both documents and CSCI had been notified of any serious incidents at the home. Accidents are analysed on a monthly basis by the manager. Records were seen that showed that all equipment including bathing equipment, fire equipment, hoists, and electrical equipment were subject to regular checks and had been serviced. Records in relation to the health and safety of residents such as temperature checks of food served were seen to be kept by staff. The training record provided, showed that that staff had received mandatory training and updates and also a range of specialist training. Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 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 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 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 2 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X 3 3 X X 3 Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 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 OP8 Regulation 13(4)(c) Timescale for action All residents must have a moving 31/08/06 and handling risk assessment undertaken on admission and updated and reviewed as necessary. Pressure sore (Waterlow) risk 31/08/06 assessments must be undertaken on admission and reviewed regularly to reflect individual current needs. The registered manager must 31/08/06 ensure that the sluice is kept locked at all times. The laundry must be kept clean 31/08/06 and tidy. The registered manager must 31/08/06 ensure that at least 2 references are obtained before new staff are employed. Requirement 2 OP8 13(4)(c) 3 4 5 OP19 OP26 OP29 13(4)(a) 23(2)(d) 19(1)(b) (c) Schedule 2(5) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 Page 26 No. 1 2 Refer to Standard OP3 OP7 Good Practice Recommendations The registered manager should ensure that all documentation is fully completed, dated and signed The registered manager should ensure that all care plans are reviewed monthly with residents and that they are asked to sign their agreement to the plan if they are able to do so. All residents should have a nutritional risk assessment undertaken on admission and regularly thereafter as necessary. Assessments should be updated as necessary to reflect changing needs and give staff current information about residents care and health needs. The information in the Statement of Purpose regarding the action to be taken by the home should a serious allegation be received should be updated to reflect current good practice advice The information in the Statement of Purpose regarding the action to be taken by the home should a serious allegation be received should be updated to reflect current good practice advice Serious consideration should be given to installing a keypad system on exterior doors to ensure the safety of residents. All residents should be offered the opportunity to have a bedside light if they so wish. Advice should be sought from the Health Protection Agency on the practice of using latex rather than vinyl gloves. All staff should be given terms and conditions of their employment. Experienced members of staff should undertake induction training and support for new staff. 3 4 5 OP7 OP7 OP1 6 OP18 7 8 9 10 11 OP19 OP19 OP26 OP29 OP30 Portcullis House DS0000016076.V305080.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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