Inspection on 26/07/05 for Portcullis House

This inspection was carried out on 26th July 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 02/11/05

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 26th July 2005 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 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 D53 - D02 S16076 Portcullis House V235906 140705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Portcullis House Address The Embankment Langport Somerset TA10 9RZ 01458 250800 01458 253772 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Somerset Care Limited Mrs Christine Carol Dowdell Personal Care Only 40 Category(ies) of Old Age registration, with number Dementia - over 65 of places Portcullis House D53 - D02 S16076 Portcullis House V235906 140705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered for 40 persons in categories OP and DE (E). Date of last inspection 18th January 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 with all levels of mobility. 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. The home is owned by Somerset Care Limited, and the Registered Manager is Mrs Christine Dowdell. 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 dementia care needs. Day care is also offered at the home, including services for those with specialist mental health needs. Portcullis House D53 - D02 S16076 Portcullis House V235906 140705 Stage 4.doc Version 1.40 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 carried out by one inspector over one day. The previous inspection was announced and took place on 18th January 2005. On the day of the inspection there were thirty-two 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. The Inspector would like to thank the Registered Manager, staff and service users for their assistance throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: Where an assessment indicates that a service user is at high risk of developing a pressure sore, a record must be maintained of the actions being taken to address this need. Portcullis House D53 - D02 S16076 Portcullis House V235906 140705 Stage 4.doc Version 1.40 Page 6 The home must ensure that when a definition is used on medication records that this is clearly explained. An opening or expiry date should be recorded for all creams and liquid preparations. The toilets located close to the lounge require re-furbishment. The home must take appropriate action to ensure that service users are not put at risk from unrestricted window openings on upper floors. In order to reduce the risk of cross infection, tablets of soap and unnamed toiletries must not be available in communal bathrooms. 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 D53 - D02 S16076 Portcullis House V235906 140705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Portcullis House D53 - D02 S16076 Portcullis House V235906 140705 Stage 4.doc Version 1.40 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 standard(s) 1,3,4 & 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. EVIDENCE: The home has a Statement of Purpose and Service User Guide that provide details of the services and facilities provided at Portcullis House. An assessment of needs is completed prior to a service user moving into the home. Completed pre-admission assessments were found within service user plans. Service users confirmed that they were able to visit the home before moving in. Portcullis House D53 - D02 S16076 Portcullis House V235906 140705 Stage 4.doc Version 1.40 Page 9 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 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, psychological and social care 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 are provided with appropriate medications training. Staff treat service users with dignity and respect. EVIDENCE: Care plans are maintained for each service user. Three care plans were examined in detail. These are developed within the first month of a service user being admitted to the home, and provide details of their needs, preferences and daily routines. Risk assessments and falls analysis are completed where required. Two of the care plans seen included a moving and handling assessment. Care plans had been regularly reviewed and updated as necessary. The home supports service users in accessing healthcare services. The District Nursing team provide assistance as required. The Specialist Link Nurse visits Rose Garden each week, and provides support and guidance to the staff team. Portcullis House D53 - D02 S16076 Portcullis House V235906 140705 Stage 4.doc Version 1.40 Page 10 The home also ensures that specialist advice is sought as necessary from other professionals such as from the Dietician, or Continence Nurse. The home takes appropriate action to monitor service users nutritional intake, and service users are weighed on a monthly basis. A Waterlow assessment is completed for each service user. Where the 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. 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. All hand transcribed entries had been supported by two staff signatures. 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 creams and liquid preparations. Portcullis House D53 - D02 S16076 Portcullis House V235906 140705 Stage 4.doc Version 1.40 Page 11 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 standard(s) 12,13,14 & 15 The home has taken appropriate action to meet individual service users’ social needs. Service users are encouraged to exercise choice over their lives. Meals are of a high standard and offer a well-balanced diet. EVIDENCE: Service users are encouraged to maintain interests and hobbies. Staff are available each day to provide assistance to service user in meeting their social needs. The home has recently undertaken work to increase the range of activities available to service users living in Rose Gardens. A range of activities are available throughout the home, which include: walks, quizzes, manicure, hand massage, knitting, reminiscence, sing a long and flexercise. 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. Visitors are welcomed. Service users are encouraged to continue to attend luncheon clubs and activities outside of the home wherever possible. Ministers from local churches regularly visit the home. Portcullis House D53 - D02 S16076 Portcullis House V235906 140705 Stage 4.doc Version 1.40 Page 12 Service users spoke highly of the food provided. A daily menu is displayed. A choice of meals is offered. The home is able to cater for specialist diets and staff are aware of service users dietary preferences and needs. Portcullis House D53 - D02 S16076 Portcullis House V235906 140705 Stage 4.doc Version 1.40 Page 13 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 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. There have been two complaints received by the home since the last inspection. These have been responded to in a timely manner and appropriate action has been taken to address the issues raised. The home has policies relating to the protection of vulnerable adults and whistleblowing. Portcullis House D53 - D02 S16076 Portcullis House V235906 140705 Stage 4.doc Version 1.40 Page 14 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 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 offers a range of communal areas. Appropriate adaptations have been provided to meet service users’ needs. Window openings had not been restricted on upper floors. Staff must ensure that good practice is followed with regard to infection control. 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 D53 - D02 S16076 Portcullis House V235906 140705 Stage 4.doc Version 1.40 Page 15 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. There are communal toilets located throughout the building. Those situated close to the lounge require upgrading. There is an on-going program of re-decoration and re-furbishment throughout the home. A new maintenance person has just been employed. Radiators have been guarded. Devices have been installed to restrict window openings on the first floor. However these were not in use on windows in some service user rooms and communal areas. Hot water outlet temperatures were tested and found to be within appropriate limits. Hand washing facilities consisting of liquid soap and paper towels had been provided in bathrooms and toilets. Tablets of soap, a nailbrush and unnamed toiletries were found within the first floor bathrooms. The laundry was clean and well organised. The home has been maintained to a high standard of cleanliness. Portcullis House D53 - D02 S16076 Portcullis House V235906 140705 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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. The Registered Manager monitors staffing levels closely and is currently reviewing staff arrangements within the home. Feedback from service users indicated that there were sufficient staff on duty 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. Staff are encouraged to study for NVQ qualifications. The Registered Manager has obtained the NVQ level 4 qualification. Sixty-four per cent of the care staff employed have obtained the NVQ level 2 qualification in direct care and a further seven staff are completing study for this. 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 D53 - D02 S16076 Portcullis House V235906 140705 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,36,37 & 38 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 relating to health and safety have been appropriately maintained. 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 qualification. Staff and service users stated that she was 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 informal basis. Regular meetings are also held. Portcullis House D53 - D02 S16076 Portcullis House V235906 140705 Stage 4.doc Version 1.40 Page 18 Staff are provided with appropriate supervision. All records relating to service users are stored securely and the home displays appropriate Employers Liability Insurance. Fire safety records were examined and found to be up to date. It is recommended that emergency lighting be tested on a monthly basis. The kitchen was found to have a high standard of cleanliness and cleaning rotas had been appropriately maintained. The passenger lift, hoist and bath hoists had serviced within the last six months as required under LOLER regulations. The Registered Manager will ensure that sit on scales are calibrated on a regular basis to ensure that reading are accurate. Accidents are recorded and reported as required. Portcullis House D53 - D02 S16076 Portcullis House V235906 140705 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 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 3 4 2 3 3 3 2 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 3 x 3 3 3 Portcullis House D53 - D02 S16076 Portcullis House V235906 140705 Stage 4.doc Version 1.40 Page 20 yes 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 OP8 Regulation 12(1) & 13(5) Requirement Where a Waterlow assessment indicates that a service user is at high risk of developping a pressure area, a record must be maintained of the actions being taken to address this need. A moving and handling assessment must be completed for each service user admitted to the home. Where a definition is used, a clear record must be maintained explaining what the abbreviation means. An opening or expiry date must be recorded for all liquid preparations and creams. (previous timescale of 4.2.05 not met) The toilets located close to the lounge require re-decoration. The home must ensure that window openings are restricted on upper floors, and that where these are not restricted, that there are appropriate risk assessments in place. In order to reduce the risk of cross infection, tablets of soap, Timescale for action 16.9.05 2. OP9 13(2) 19.8.05 3. 4. OP21 OP25 23(2) 13(4) 31.3.06 16.9.05 5. OP26 13(3) 19.8.05 Page 21 Portcullis House D53 - D02 S16076 Portcullis House V235906 140705 Stage 4.doc Version 1.40 nailbrushes and unnamed toiletries must not be available in communal bathrooms. 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 D53 - D02 S16076 Portcullis House V235906 140705 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier 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 D53 - D02 S16076 Portcullis House V235906 140705 Stage 4.doc Version 1.40 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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