Inspection on 16/02/06 for Portelet Lodge

This inspection was carried out on 16th February 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Portelet Lodge 25/05/06

Portelet Lodge 12/07/05

Portelet Lodge 02/09/04

Portelet Lodge 08/04/04

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

CARE HOMES FOR OLDER PEOPLE Portelet Lodge 42 Westby Road Boscombe Bournemouth Dorset BH5 1HD Lead Inspector Jo Palmer Unannounced Inspection 11:15 16 February 2006 th 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 Portelet Lodge DS0000053933.V271719.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. Portelet Lodge DS0000053933.V271719.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Portelet Lodge Address 42 Westby Road Boscombe Bournemouth Dorset BH5 1HD 01202 398982 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) porteletlodge@tiscali.co.uk Portelet Care Ltd Miss Sarah Louise Joyner Care Home 21 Category(ies) of Dementia - over 65 years of age (21), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (21) Portelet Lodge DS0000053933.V271719.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. In addition to registered places a day care service of up to 7 hours per day may be provided for two people in the categories MD(E) DE(E). 12th July 2005 Date of last inspection Brief Description of the Service: Portelet Lodge is a care home registered with the Commission to provide personal care and accommodation for 21 people over the age of 65 years who have mental health needs. Portelet Lodge is registered under the company name Portelet Care Limited, one of whose directors is the responsible individual for Portelet Lodge. Sarah Joyner is the registered manager. Portelet Lodge is situated in a residential area of Boscombe, Bournemouth, and is a short walk from local shops and amenities and the sea front. Accommodation is provided over three floors; a five-person passenger lift provides access between floors along with a central stairway. There are fifteen single rooms, eleven of which have en-suite facilities, and three shared rooms all with en-suites. On the ground floor there is a communal lounge and dining area and a conservatory opening up to the rear garden. The gardens are secure and provide seating for residents. The front of the home provides off road parking for five or six cars, parking on Westby Road is available although limited. Portelet Lodge DS0000053933.V271719.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection on 16th February 2006 lasted for three hours. David Lallana, registered provider and Sarah Joyner, registered manager were present and assisted throughout the inspection providing necessary information and access to records. This was a brief inspection the purpose of which was to review practices in relation to some of the National Minimum Standards. Not all standards were assessed and the reader is referred to the report of the last inspection dated 12th July 2005, which can be obtained either from the home or can be viewed on www.csci.org.uk The inspector spoke with four residents, two members of staff, Sarah Joyner and David Lallana, met with one relative, residents and examined relevant records. The Commission sent comment cards to the home prior to the inspection to be distributed to relatives, GPs, visiting health care professionals and care managers. At the time of writing the report, one had been returned from a care manager, one from a GP, and two from relatives. Although this is a limited response and not representative of all the people with an interest in Portelet Lodge, comments received on cards are included in relevant sections throughout this report. What the service does well: Residents and their representatives are provided with sufficient information about the service provided at Portelet Lodge in the form of a Service User Guide and Statement of Purpose. It was evident that residents are able to maintain contact with their friends and families, visiting is encouraged and facilities of the local community are used as appropriate depending on residents needs and abilities. There have been no complaints received either by Portelet Lodge or by the commission in respect of the care and services provided and residents are assured through written procedure that their concerns will be taken seriously and managed effectively. The registered persons ensure that equipment in the home is satisfactorily maintained and that any repairs and refurbishment takes place as required. Portelet lodge is clean and well maintained with comfortable, homely surroundings. Recent investment in upgrading the water supply system has Portelet Lodge DS0000053933.V271719.R01.S.doc Version 5.0 Page 6 ensured that safety is maintained for residents and the homes laundry system operates well. Staff are employed in sufficient numbers to meet the needs of residents, Mr Lallana confirmed that he is currently fortunate to have a committed and enthusiastic staff group. Records seen evidenced that staff are employed following suitable vetting procedures to ensure their suitability to work with vulnerable adults. Staff training opportunities are good and staff are encouraged to develop their skills by undertaking an NVQ award in care. Statutory training courses have been provided to ensure residents are in safe hands. The views of relatives have been sought by means of satisfaction questionnaires, Mr Lallana confirmed that where comments were received where improvements could be made, these were addressed at the time, there is however, no development plan or audit of the service. For those residents who require assistance managing their personal allowances, the home ensures good procedures are followed and accurate records are maintained. Staff receive regular supervision where they have the opportunity to discuss their role within the home, all areas of practice and any training or development needs. Fire safety is maintained by regular checks and servicing of equipment, emergency lighting and staff fire training. What has improved since the last inspection? What they could do better: A requirement has been made as a result of this inspection that an annual development plan is produced based on findings of the home’s quality audit programme. Whilst it is acknowledged that the registered persons take action regarding any suggested improvements as they arise, it is necessary for an audit report to be made available to the residents and the Commission. A recommendation of previous inspections is repeated that the premises are assessed in order to ensure any necessary aids and adaptations are made to maximise resident’s independence in accessing all areas of the home. Portelet Lodge DS0000053933.V271719.R01.S.doc Version 5.0 Page 7 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. Portelet Lodge DS0000053933.V271719.R01.S.doc Version 5.0 Page 8 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 Portelet Lodge DS0000053933.V271719.R01.S.doc Version 5.0 Page 9 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. Standard 6 is not applicable The home’s Service User Guide and Statement of Purpose provide residents and their representatives with sufficient information about the care and services at Portelet Lodge. EVIDENCE: A copy of the home’s Statement of Purpose and Service User Guide were not directly examined during this visit although Mr Lallana confirmed that a recent review of the information had resulted in no changes from the copy held on file with the Commission. A review of the Commission’s copy of the Service User Guide evidenced that all relevant information is held in order that residents and their representatives can make an informed choice prior to moving to Portelet Lodge based on the information provided. Standards 2, 3 and 4 were not assessed, the last inspection identified these as met. Portelet Lodge DS0000053933.V271719.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): None of these standards were assessed; the last inspection dated 12th July 2005 reported these as met although a good practice recommendation was made in respect of standard 7. EVIDENCE: Although care outcomes were not assessed in respect of these standards, the registered persons were able to evidence that a recommendation of the last inspection had been addressed. It had been recommended that care records detail the residents participation in the process or, where they are unable to contribute, evidence that their representative had been consulted. A preadmission assessment format seen identified the source of the information obtained and detailed the involvement of the relative. Mr Lallana confirmed it is now standard practice to record this information. Whilst these standards were not assessed, residents spoken with who were able to comment, confirmed that staff treat them well and that their care needs are met. Comment cards received from a GP and a care manager indicated satisfaction with the service provided at Portelet Lodge. Two comment cards received from relatives confirmed that the care and services provided were good, one stating that ‘I cannot speak too highly of the way the staff show care and patience and warmth…they are all very kind’. Portelet Lodge DS0000053933.V271719.R01.S.doc Version 5.0 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 the following standard(s): 13 Residents are supported in maintaining contact with their friends, family and the local community. EVIDENCE: Residents spoken with that were able to comment confirmed that they were able to receive visitors. One resident confirmed that there were no restrictions on going out into the local town as long as staff were aware, not all residents retain the ability to go out unescorted. One visitor spoken with confirmed that they were able to visit when they pleased and were made to feel welcome. Standards 12, 14 & 15 were not assessed; the last inspection reported that these standards were met. Portelet Lodge DS0000053933.V271719.R01.S.doc Version 5.0 Page 12 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 Residents and relatives can be confident that their complaints will be listened to and taken seriously. EVIDENCE: The complaints procedure was not assessed, the last inspection reported this standard as met and comment cards returned from relatives for the purpose of this inspection confirmed that they were aware of the home’s complaints procedure. Mr Lallana confirmed that no complaints had been received. The last inspection reported that standard 18 was met and that satisfactory policies and procedures were in place to inform staff of action necessary and reporting details if any form of abuse is suspected. Portelet Lodge DS0000053933.V271719.R01.S.doc Version 5.0 Page 13 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, 22, 25 & 26 Portelet Lodge is clean and well maintained and routine maintenance schedules ensure residents health and welfare through regular checking and servicing of equipment and general maintenance. The premises have not been assessed to ensure that resident’s mobility needs are optimised although individual risk assessments are in place to protect residents from potential hazards. Recent upgrading of the heating and water systems has benefited resident’s safety and the home’s laundry provides a good service. EVIDENCE: Mr Lallana confirmed that resident bedrooms are decorated as necessary and new flooring has been laid in some parts of the home. Those areas briefly seen including hallways and corridors were in a good state of repair. There is no written schedule of routine maintenance in respect of redecoration although planned servicing and maintenance of all equipment is carried out to a prescribed schedule. Ms Joyner confirmed that a maintenance record is available for staff to write in any items that they notice needing attention from replacement light bulbs to broken furniture etc. the home’s maintenance person attends to these jobs as a matter of course. Portelet Lodge DS0000053933.V271719.R01.S.doc Version 5.0 Page 14 A recommendation of the last inspection is repeated that a qualified person (an occupational therapist) carries out an assessment of the premises to ensure that suitable aids and adaptations are in place to aid resident’s mobility throughout all areas of the home. Whilst this remains a recommendation, no concerns were noted concerning access around the home during this inspection. Although the water distribution system was being reviewed a the time, a requirements was made at the last inspection to ensure that water was stored and distributed at correct temperatures in compliance with the Water Supply Regulations. Works have been completed to upgrade the system and confirmation from Bournemouth and West Hampshire Water plc was seen evidencing that the system now complies with the regulations. Parts of the premises seen were clean and well maintained and free from offensive odours. A laundry area is sited to the rear of the home where a commercial washing machine with a sluicing programme and capacity to reach a temperature of 95°C and a tumble dryer are used for laundering of all resident clothing, towels and linen in the home. Ms Joyner confirmed that all residents clothing is labelled to ensure it is returned correctly; residents spoken with were well presented in clean and well-maintained clothing. Portelet Lodge DS0000053933.V271719.R01.S.doc Version 5.0 Page 15 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 home employs enough staff to meet the needs of residents and to ensure their safety, care and comfort. Recruitment and employment practices are designed to minimise the risk of unsuitable staff being employed. Learning opportunities for staff are good and most staff have carried out the appropriate training to ensure residents are in safe hands and are protected. EVIDENCE: Staff at Portelet Lodge work varying shifts including day and night duty; this ensures a consistency of approach for residents. A set rota is maintained although changes requests are recorded in a diary where the actual shifts worked by staff were evident. There are four care staff (including a senior) each morning and afternoon and two care staff at night. Shifts are worked between 7.30am and 2.00pm, 2.00pm and 9.00pm and 9.0pm until 7.30 am. Sarah Joyner, registered manager, works additionally to these numbers. A separate rota is held demonstrating hours spent in the home by senior staff including Mr & Mrs Lallana. Comment cards returned from relatives, a care manager and GP confirmed that there are sufficient numbers of staff on duty and that a senior person is available to maintain good communications. Mr Lallana confirmed that one member of staff has attained level 2 at NVQ, three staff attained level 3 and two staff have the equivalent qualification; confirmation from the National Recognition Information Centre for the UK seen Portelet Lodge DS0000053933.V271719.R01.S.doc Version 5.0 Page 16 demonstrating that nursing qualifications obtained overseas for these two staff members is equivalent to an NVQ award. Three staff files were examined, these contained relevant documentation evidencing that recruitment procedures are sound ensuring that all staff employed are fit to undertake their duties, references from previous employers are held, evidence that CRB* and POVA* checks have been carried out and that work history and qualifications claimed have been explored. Staff files contain evidence that an in-house induction has taken place ensuring that staff are made familiar with the home’s policies and procedures, introduced to their role, are well informed about the home’s emergency procedures. Shortly after commencing employment, staff are booked onto an induction training programme, run by the local authority in accordance with National Training Organisation specification. A work book seen evidenced that the induction covers the TOPSS* units of induction, the registered persons are reminded that Skills for Care (formerly TOPSS) are reviewing the induction and foundation standards and they must ensure that their training provider recognises this. Information on the Common Induction Standards can be obtained from www.skillsforcare.org Mr Lallana confirmed that a number of staff have undertaken statutory training in areas relating to food hygiene, first aid, moving and handling and infection control. * CRB – Criminal Records Bureau * POVA - Protection of Vulnerable Adults, a list held by the Secretary of State of persons deemed unsuitable to work with vulnerable adults. * TOPSS – Training Organisation for Personal Social Services. Portelet Lodge DS0000053933.V271719.R01.S.doc Version 5.0 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 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): 33, 35, 36 & 38 The use of questionnaires to obtain views of residents and relatives has been good although the value of these in setting targets for improvement and reviewing performance is compromised as results have not been evaluated and there is no clear development plan for the home. Resident’s financial interests are safeguarded by efficient record keeping ensuring that resident’s rights and best interests are protected. Good practice is measured and maintained by the management’s approach to staff supervision ensuring that all staff have the opportunity to discuss their training and development needs and all areas of practice. Regular checking of fire equipment and staff fire training ensures that good fire safety procedures are in place to protect residents, staff and the premises. Portelet Lodge DS0000053933.V271719.R01.S.doc Version 5.0 Page 18 EVIDENCE: Questionnaires have been used to obtain the views of interested parties on the care and services provided by the home. Sarah Joyner and Mr Lallana confirmed that any comments or suggestions for improvement made on returned questionnaires had been dealt with as they arose, for example, a suggestion was made concerning the carpet in the dining room; the floor covering has now been replaced with a more hygienic linoleum and from another suggestion, a hand rail has been place in a bathroom. Results of the questionnaires however have not been audited and other aspects of service provision have not been measured to ensure the home is meeting its stated aims and objectives. Mr Lallana confirmed that questionnaires are issued annually and following this year’s distribution, a development plan would be produced. In view of forthcoming changing practices to regulation where care homes will be required to undertake a self-assessment process to ensure compliance with the regulations and that standards are met, it had been made a requirement that a development plan is produced and a copy sent to the Commission. Portelet Lodge takes responsibility for managing some residents personal allowances, records seen evidenced that accurate accounting procedures are employed with the record of income, expenses and balances being accurately recorded. Receipts are held for all purchases and relatives or representatives are kept informed of expenditure. One balance of money held was seen and counted and noted to be accurate, all money is held securely. Staff files examined held a record of regular supervision, each member of staff receives one to one supervision with the manager during which time all areas of practice are discussed and training needs, supervision provides the opportunity for staff to air any concerns regarding their employment or suggestions for change to the working environment or routine. Staff spoken with confirmed that eh system of supervision was good and that Sarah Joyner or David Lallana were always available to discuss any issues. It was evident that staff are confident in their communications with management and that they consider Portelet Lodge a good place to work, a commitment to resident care was also evident and staff were observed in their relations with residents to be considerate and respectful. Standard 38 was not wholly assessed but examination of certificates and records of maintenance and servicing of emergency lighting, fire alarm systems and fire fighting equipment demonstrated that fire safety is promoted. Staff receive fire training at regular intervals. Portelet Lodge DS0000053933.V271719.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X 2 X X 3 3 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 X X 1 X 3 3 X 3 Portelet Lodge DS0000053933.V271719.R01.S.doc Version 5.0 Page 20 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. Standard Regulation Requirement The registered persons must establish and maintain a system for reviewing and improving the quality of care in the home, a report of any such review must be provided to the Commission and be available to service users Timescale for action 1 OP33 24 30/06/06 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 OP22 Good Practice Recommendations It is recommended that the Portelet Lodge premises be assessed by suitably qualified persons including an Occupational Therapist. 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