CARE HOMES FOR OLDER PEOPLE
Portland House Portland Road Kirby Muxloe Leicestershire LE9 2EH Lead Inspector
Keith Charlton Unannounced 2 September 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. Portland House DC51 C01 Portland House V246979 020905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Portland House Address Portland Road Kirby Muxloe Leicestershire LE9 2EH 0116 2386444 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) Ms Karen Stevenson and Ms Theresa Poynton Ms Karen Stevenson Care Home 19 Category(ies) of OP Older People - 19 registration, with number DE(E) Dementia over 65 - 7 of places MD(E) Mental disorder over 65 - 7 Portland House DC51 C01 Portland House V246979 020905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: - Date of last inspection 23/2/2005 Brief Description of the Service: Portland House is a long established home in the village of Kirby Muxloe and is situated in a quiet residential part of the village.The rooms in this home are a mixture of double and single occupancy and many have a pleasant view over the gardens.The home is generally well decorated and comfortably furnished. The home is continuing to upgrade redecoration in 2005.The gardens form an attractive area for service users to use if they wish to sit outside.There are a variety of lounges and service users can choose to sit in whichever one they choose. Portland House DC51 C01 Portland House V246979 020905 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service user and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting two service users and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. This was an unannounced Inspection; the Deputy Manager was on duty. Planning for the Inspection included reading the Pre-Inspection Questionnaire completed by the Manager and the Comment Cards returned by relatives. The notifications of significant events sent to the Commission for Social Care Inspection were also reviewed. There have been no complaints regarding the service since it was taken over by the Registered Providers. The Inspection took place between 9.35 and 13.30 and included a tour of the building, inspection of records and direct and indirect observation of care practices. The Inspector spoke with eight residents, three members of staff, two relatives and the Deputy Manager. What the service does well: What has improved since the last inspection?
Staff training has been provided in respect of whistle blowing, stroke and infection control, in order to provide a safer standard of care. Some attention has been paid to paintwork in order to improve the environment. Staff records have been improved to ensure that staff are suitable before they commence employment. Portland House DC51 C01 Portland House V246979 020905 Stage 4.doc Version 1.40 Page 6 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. Portland House DC51 C01 Portland House V246979 020905 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 Portland House DC51 C01 Portland House V246979 020905 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) 3 The assessment process ensures that prospective service user’s needs can be met. EVIDENCE: An assessment form for prospective service users is in operation; it includes all issues regarding service users needs, as per the National Minimum Standards. Portland House DC51 C01 Portland House V246979 020905 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) 7,10 Service users are treated with respect and care is delivered to meet their assessed needs. EVIDENCE: Staff were observed to be friendly and respectful in their dealings with service users; the service users spoken with said staff were caring towards them. Both of the tracked service users identified had a particular plan of care though there were some gaps regarding health checks. Staff confirm that they read and follow Care Plans. Portland House DC51 C01 Portland House V246979 020905 Stage 4.doc Version 1.40 Page 10 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) 12,13,15 Service users’ lifestyle needs and choices are met. EVIDENCE: Staff played skittles with service users during the inspection. There were comments from service users that they were generally satisfied with activities though they would like more outings. Service users said that visitors were always made welcome and the comment cards completed by relatives confirmed this. Service users said that the food was good; the meal observed smelled and generally tasted well though there were a number of bones in the fish, which could have posed a Health and Safety risk to service users. The cook said that she was aware of service users likes and dislikes and she frequently asked about whether they liked the food; this was observed. She said that usually there was a choice of fresh vegetables; records showed a choice of food was available. Portland House DC51 C01 Portland House V246979 020905 Stage 4.doc Version 1.40 Page 11 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) 18 Service users/their representatives can be confident their concerns will be properly attended to. EVIDENCE: Staff spoken to knew to take their concerns further in abuse was suspected and were aware of all relevant agencies to contact in the event of action not being taken by management. Portland House DC51 C01 Portland House V246979 020905 Stage 4.doc Version 1.40 Page 12 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 Facilities are generally attractive though in further need of improvement. EVIDENCE: Service users were satisfied with their bedrooms. The facilities need to continue to be upgraded to ensure that repainting is carried out with regard to doorways, skirting, paintwork to some toilet en suites, the ground floor toilet and outside windows. This work would make the environment more pleasant for service users. The Deputy Manager said the roof is to be repaired. Portland House DC51 C01 Portland House V246979 020905 Stage 4.doc Version 1.40 Page 13 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) 27,29 Staffing levels meet service users needs and the recruitment process protects service users. EVIDENCE: Staffing levels for the week beginning 29/8/05 were found to meet required levels – there are a minimum of three care staff on each daytime shift. The Registered Manager is organising domestic cover seven days a week instead on the present four days a week. Some staff records had essential information with regard to references and Protection of Vulnerable Adults checks but some statutory identification was missing; the Deputy Manager said this would be followed up. Portland House DC51 C01 Portland House V246979 020905 Stage 4.doc Version 1.40 Page 14 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) Not applicable EVIDENCE: Portland House DC51 C01 Portland House V246979 020905 Stage 4.doc Version 1.40 Page 15 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 2
COMPLAINTS AND PROTECTION 2 x x x x x x x STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x x x x x x x Portland House DC51 C01 Portland House V246979 020905 Stage 4.doc Version 1.40 Page 16 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. 2. Standard 15 19 Regulation 13 16 Requirement Food needs to be monitored to ensure it poses no health and safety issues for residents. Repainting is needed to some areas of facilities and the roof needs repair. Timescale for action 2/9/05 2/11/05 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. 2. 3. Refer to Standard 13 19 19 Good Practice Recommendations It is recommended that an outings programme is set up based on residents choice. Residents would benefit from having a floor draining shower on the first floor to make this facility more accessible. A loop system would assist service users with hearing difficulties. Portland House DC51 C01 Portland House V246979 020905 Stage 4.doc Version 1.40 Page 17 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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