Inspection on 02/11/05 for Portcullis House

This inspection was carried out on 2nd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Portcullis House 06/11/07

Portcullis House 19/07/06

Portcullis House 26/07/05

Portcullis House 18/01/05

Portcullis House 07/07/04

Portcullis House 26/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Portcullis House The Embankment Langport Somerset TA10 9RZ Lead Inspector Sally Murphy Unannounced Inspection 2nd November 2005 10:00 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.V263216.R01.S.doc Version 5.0 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.V263216.R01.S.doc Version 5.0 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.V263216.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. REGISTERED FOR 40 PERSONS IN CATEGORIES OP AND DE (E) Date of last inspection 19th July 2005 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.V263216.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out as part of the planned annual programme of inspection. The inspection was unannounced and was carried out over one day. The inspection was completed by Sally Murphy, Regulation Inspector. Marian Storey, Business Services Administrator from CSCI also visited the home. The previous inspection was announced and took place on 19th July 2005. On the day of the inspection there were thirty-nine service users residing at the home. During the course of the inspection service users, relatives and staff members were spoken with. Care practice was also observed, records examined and a tour of the premises was made. What the service does well: What has improved since the last inspection? The home has continued to support staff in receiving further training. Many of the care staff employed have obtained the NVQ level 2 qualification in care. Staff have been working to improve the range of activities provided. Additional activities equipment and materials have been purchased. Staff have sought to make the environment and garden area more stimulating for those service users living within Rose Garden. Portcullis House DS0000016076.V263216.R01.S.doc Version 5.0 Page 6 The passenger lift has been upgraded. The home is about to introduce a new system for the recording of prescribed creams. 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. Portcullis House DS0000016076.V263216.R01.S.doc Version 5.0 Page 7 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.V263216.R01.S.doc Version 5.0 Page 8 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 does not apply). Service users are provided with appropriate information regarding the services and facilities offered at the home. An assessment of need is completed prior to admission to ensure that the home will be able to fully meet their needs. Service users are provided with a written contract outlining the terms and conditions of their stay. EVIDENCE: The home has a Statement of Purpose and Service User Guide that provide details of the services and facilities provided at Portcullis House. The Statement of Purpose includes a copy of the most recent inspection report, and is available in the hallway of the home. The Registered Manager ensures that a comprehensive assessment is completed prior to any service user moving in, to ensure that they home will Portcullis House DS0000016076.V263216.R01.S.doc Version 5.0 Page 9 be able to fully meet their needs. Completed pre-admission assessments were found within service user plans. Service users confirmed that they were able to visit the home before moving in. Service user contracts provided details of any notice periods required, and had been signed by both parties. Portcullis House DS0000016076.V263216.R01.S.doc Version 5.0 Page 10 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 home works closely with social and healthcare professionals to ensure that they are able to meet service users health, social care and psychological needs. Care plans are of a good standard and promote independence. Records had not been maintained of the actions being taken to address the needs of service users identified as being at high risk of developing a pressure area. Staff must take further action to ensure that the recording of medications follows best practice. EVIDENCE: Care plans are maintained for each service user. Four care plans were examined in detail. Care plans include a photograph of the service user, and provide details of individuals’ needs, preferences and daily routines. A moving and handling assessment had been completed for each service user. Care plans are regularly reviewed, and included evidence of service user consultation. Staff support service users in accessing health care services. The Specialist Link Nurse visits Rose Garden each week. Waterlow assessments are Portcullis House DS0000016076.V263216.R01.S.doc Version 5.0 Page 11 completed. Where a service user is identified as being at high risk of developing a pressure sore, a record must be maintained of the actions being taken to address this need. Service users are weighed regularly and their nutritional intake monitored appropriately. Risk assessments are completed in relation to the use of bed rails. On the day of the inspection bed rails in one room were found to pose a potential risk of entrapment. Falls risk assessments are completed. 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 not been confirmed by a second staff signature. Variable doses are recorded. The home must ensure that where definitions such as S or O are used, that it is clearly stated what the abbreviation means. An opening or expiry date should be recorded for all prescribed creams. Portcullis House DS0000016076.V263216.R01.S.doc Version 5.0 Page 12 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. Service users are able to participate in a range of social activities, and are encouraged to exercise choice over their daily lives. Meals are of a high standard and offer a well-balanced diet. EVIDENCE: Care plans provide details of service users’ social needs. The Occupational Therapist from Somerset Care Limited visits the home each week, to offer support and guidance to the staff team. Service users are encouraged to maintain interests and hobbies. One service user enjoys gardening and has had tomato plants in the green house. The home has undertaken work to increase the range of activities available to service users living in Rose Gardens. Service users spoken with stated that they had enjoyed the recent Halloween Party. Trips are also provided. In response to service users enjoying visits from the donkey sanctuary, a donkey has been adopted by the home. Daily routines are flexible. Service users are able to spend time within communal areas, or their own room, as they prefer. Service users are encouraged to continue attending luncheon clubs and activities outside of the Portcullis House DS0000016076.V263216.R01.S.doc Version 5.0 Page 13 home wherever possible. Ministers from local churches regularly visit the home. Visitors are welcomed. Relatives spoke highly of the service provided and stated that there was good communication with the home. 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 service users dietary preferences and needs. Homemade cakes are prepared each day. The main meal is served at midday. Vegetable are placed in serving dishes on each table so that service users may choose which they have. Condiments were available. Service users spoke very highly of the meals provided. Portcullis House DS0000016076.V263216.R01.S.doc Version 5.0 Page 14 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 home has taken appropriate action to safeguard vulnerable service users. EVIDENCE: The home has a complaints procedure. This includes details of external agencies that service users and their families may contact, such as CSCI. The home has policies relating to the protection of vulnerable adults and whistleblowing. Portcullis House DS0000016076.V263216.R01.S.doc Version 5.0 Page 15 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 home has been decorated and furnished to a good standard. There is an on-going program of re-decoration throughout the home. The home has a range of communal areas. Appropriate adaptations have been provided to meet service users’ needs. In order to reduce the risk of cross infection, personal possessions and toiletries must not be available within communal bathrooms. The home has been maintained to a high standard of cleanliness. EVIDENCE: Service user accommodation is provided over two floors. There is a passenger lift, assisted bathroom and call system available to service users. 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 with Rose Gardens. There is an additional dining room and lounge on the first floor and further seating areas throughout the home. Portcullis House DS0000016076.V263216.R01.S.doc Version 5.0 Page 16 Service user rooms have been pleasantly decorated. All rooms seen had been individualised to reflect individual tastes and preferences. Appropriate adaptations have been provided to meet service users’ needs. Eight service user rooms have en suite facilities. A partition or curtain must be fitted between the bedroom and ensuite facilities within the room identified in Rose Garden. There are communal toilets located throughout the building. Those situated close to the lounge require upgrading. A tile requires replacement within the shower room in Rose Garden. There is an on-going program of redecoration and re-furbishment throughout the home. Radiators have been guarded, and window openings restricted on upper floors. Emergency lighting is provided throughout the home. It is recommended that this be tested on a monthly basis. Hot water outlet temperatures were tested and found to be within appropriate limits. In order to reduce the risk of cross infection, tablets of soap, nailbrushes and combs must not be available within communal bathrooms. The laundry was clean and well organised. Alginate bags are used as required. The home has been maintained to a high standard of cleanliness. Portcullis House DS0000016076.V263216.R01.S.doc Version 5.0 Page 17 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. Staff are provided with appropriate training to undertake their role. There are sufficient staff on duty to meet service users’ needs. The home operates a robust recruitment procedure. EVIDENCE: Duty rotas are maintained. On the day of the inspection there were four senior staff, five carers, three domestic staff, a cook, kitchen assistant and laundry assistant on duty. The Registered Manager is also supernumerary to the staff team for part of the week. Service users spoke highly of the care provided and felt that staffing levels were appropriate to meet their needs. Newly appointed staff receive Induction Training. 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. Recruitment files were examined for three recently employed members of staff, and each was found to contain the documentation required under Schedule 2 of the Care Home Regulations 2001. Portcullis House DS0000016076.V263216.R01.S.doc Version 5.0 Page 18 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): The Manager provides strong leadership to the staff team, and ensures that care practices are kept under regular review. There are appropriate systems in place to obtain the views of service users and their families. Records are maintained of all transactions involving service users’ finances. Fire safety records have been appropriately maintained. Lifting equipment has been serviced in accordance with LOLER Regulations. Portable appliances must be tested on an annual basis. EVIDENCE: The Registered Manager is Mrs Christine Dowdell. She has considerable experience of providing care to older people and has obtained the NVQ level 4 Portcullis House DS0000016076.V263216.R01.S.doc Version 5.0 Page 19 qualification. Service users stated 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 service users and their families on an individual basis, and at regular meetings. Staff are provided with appropriate supervision. All records relating to service users are stored securely. The home displays appropriate Employers Liability Insurance. The home will keep money securely for any service users that wish them to. Monies are kept within one account, with each service user having an individual book providing details of their monies. Transactions involving service user finances are supported by two staff signatures and receipts are obtained. Four service user monies were examined, and each tallied with the records kept. Fire safety records were examined and found to be up to date. Since the last inspection, the passenger lift has been upgraded. Equipment servicing records had been appropriately maintained. Portable appliances had last been tested on 4/4/04. Hazardous substances were found within one communal bathroom. Accidents are recorded and are analysed on a monthly basis. Portcullis House DS0000016076.V263216.R01.S.doc Version 5.0 Page 20 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 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 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 3 3 3 2 3 3 2 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 2 Portcullis House DS0000016076.V263216.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes. 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 12(1) & 13(5) Requirement Where a Waterlow assessment indicates that a service user is at high risk of developing a pressure area, a record must be maintained of the actions being taken to address this need. Timescale for action 31/01/06 2. OP8 13(4c) 3. OP9 13(2) (Previous timescale of 16/09/05 not met). Bed rails must be monitored on a 16/12/05 regular basis to ensure that they do not pose a risk to service user, and an appropriate record maintained. Where a definition is used, a 16/12/05 clear record must be maintained explaining what the abbreviation means. All hand transcribed entries must be confirmed by a second staff signature. An opening or expiry date must be recorded for all prescribed creams. (Previous timescale of 19/8/05 not met) Portcullis House DS0000016076.V263216.R01.S.doc Version 5.0 Page 22 3. 4. OP21 OP24 23(2) 12(4a) 5. OP26 13(3) The toilets located close to the lounge require re-decoration. A partition or curtain must be fitted between the bedroom and en suite facilities within the room identified in Rose Garden. In order to reduce the risk of cross infection, tablets of soap, nailbrushes and combs must not be available in communal bathrooms. (Previous timescale of 19/08/05 not met) Portable appliances must be tested on an annual basis. Hazardous substances must be stored securely and not be accessible to service users. 31/03/06 31/12/05 16/12/05 6. 7. OP38 OP38 13(4) 13(4) 16/01/06 16/12/05 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. Refer to Standard OP38 Good Practice Recommendations It is recommended that the emergency lighting be tested on a monthly basis. Portcullis House DS0000016076.V263216.R01.S.doc Version 5.0 Page 23 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 © 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 Portcullis House DS0000016076.V263216.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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