Inspection on 22/09/06 for Portland House

This inspection was carried out on 22nd September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Portland House 29/12/05

Portland House 02/09/05

Portland House 23/02/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Portland House Portland Road Kirby Muxloe Leicestershire LE9 2EH Lead Inspector Keith Charlton Unannounced Inspection 22nd September 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Portland House DS0000061981.V310961.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Portland House DS0000061981.V310961.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Portland House Address Portland Road Kirby Muxloe Leicestershire LE9 2EH 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) 0116 2393056 0116 2393056 T.Roundtoit@aol.com Ms Karen Stevenson Mrs Teresa Poynton Ms Karen Stevenson Care Home 19 Category(ies) of Dementia - over 65 years of age (7), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (7), Old age, not falling within any other category (19) Portland House DS0000061981.V310961.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service User Numbers No person falling within categories MD(E) or DE(E) may be admitted to the home when seven persons in total of these categories/combined categories are already accommodated in the home. 29/12/06 Date of last inspection 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 2006.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. The weekly fees range from £350 to £450 approximately - this information was provided prior to the inspection. There are additional costs for individual expenditure such as hairdressing and private chiropody. Portland House DS0000061981.V310961.R01.S.doc Version 5.2 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 Registered Manager and Deputy Manager were on duty. Planning for the Inspection included reading the notifications of significant events sent to the Commission for Social Care Inspection and the Requirements from the last Inspection Report. There have been no complaints regarding the service since it was taken over by the Registered Providers either in house or received by the Commission for Social Care Inspection. The Inspection took place between 9.30 and 16.05 and included a selected tour of the building, inspection of records and indirect observation of care practices. The Inspector spoke with seven residents, three members of staff, two relatives and the Registered Manager. Seven Comment Cards were received from service users/relatives completing them on behalf of service users, and two Comment Cards were received from GPs. There was a high degree of satisfaction with the service, as testified by the following statements: ‘’The present Manager has made a number of improvements…well done to her and her team!’’ ‘’Fantastic Manager – excellent staff, friendly home’’. ‘’Very clean and no smells’’. ‘’I would not move for all the tea in China’’. What the service does well: Portland House DS0000061981.V310961.R01.S.doc Version 5.2 Page 6 Service users needs are actively promoted. Staff were aware of how to promote service users independence and this was reflected in their Care Plans. Regular activities are provided and service users asked in their meetings as to their preferred activities and outings. There was again a friendly, calm atmosphere and facilities were clean and tidy with a good degree of odour control. Bedrooms were homely and personalised with service users stating they were happy with them and they could bring in their personal possessions. Service users again said that the food was good, that staff were friendly, activities were organised including the recent outing to the garden centre, visitors are made welcome, there is always a choice of food for each meal and they did not have any restrictions on their lifestyles. Staff were again observed to be friendly and respectful towards service users. The relatives spoken to praised the service provided and said staff were always welcoming. Staff training is emphasised so that there is good awareness of service users needs, and staff feel supported in their roles by management so that a consistently good service is provided. Staff are asked to read service users Care Plans and the Policies and Procedures of the home so that they know what to do and are consistent in their work. Staff members spoken to were aware of the fire procedure. The unused downstairs lounge has been converted to an Activities Room with games, colouring, reminiscence materials, exercise machines etc available so as to provide further stimulation to service users. What has improved since the last inspection? The Registered Manager has arranged training for care staff on stroke care and depression, as these are some of the conditions experienced by some service users. There has been attention paid to improving facilities - paintwork in the downstairs corridor area and heating installed into the ground floor toilet near the dining room. Portland House DS0000061981.V310961.R01.S.doc Version 5.2 Page 7 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 DS0000061981.V310961.R01.S.doc Version 5.2 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 Portland House DS0000061981.V310961.R01.S.doc Version 5.2 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): 2,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process is generally well managed and service uses receive a generally satisfactory assessment, thereby ensuring that their health and welfare needs are being met. EVIDENCE: A service user asked said she was asked questions about what care she needed before she came into the home. The assessment form mirrors that of the National Standard, which means all essential issues of care are covered. There were a small number of gaps on forms seen by the inspector – personal safety and risk, religion, family involvement etc, which the Registered Manager said would be recorded in future. Portland House DS0000061981.V310961.R01.S.doc Version 5.2 Page 10 The service does not have intermediate care facilities. Portland House DS0000061981.V310961.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are well looked after in respect of their health and personal care, are treated with respect and have Care Plans that staff follow. EVIDENCE: Care Plans seen by the inspector contained information as to the physical, social and medical needs of service users. Staff said that they were encouraged to regularly read Care Plans to ensure they kept abreast of changing needs. Reviews are carried out to ensure identified care is still relevant. Care Plans had a small number of gaps regarding welfare needs, as some sections have not been completed with reference to e.g. regular dental visits and a Risk Assessment regarding how to deal with the challenging behaviour of one service user. Care records were kept on a daily basis and were detailed as to the service users care needs. Portland House DS0000061981.V310961.R01.S.doc Version 5.2 Page 12 Service users said when they felt ill then staff would swiftly summon medical assistance - service users contacts with medical personnel were documented in their Care Plans. Accident records were checked and staff were seen to have acted appropriately in most incidents though medical authorities were not always referred to when there was a head injury. The Registered Manager said that staff would be reminded as to the medical alert procedure to ensure this was always acted upon in future. The Registered Manager in a subsequent telephone call confirmed this as being actioned. There were a small number of instances where service users welfare issues had not been reported to the Commission for Social Care Inspection, as needed by the Care Standards Act 2000. The Registered Manager subsequently carried this out. Some service users are able to self medicate if assessed as safe to do so though all asked appreciated the staff holding their tablets and giving them at proscribed times. There was evidence of staff training regarding medication. The Registered Manager and staff said that only senior care staff issued medication and only after receiving appropriate training. Staff also confirmed this. There was an observed medication policy in place. The records were well kept with no gaps. Medication was locked up securely in the medication trolley. Service users again said that their privacy and dignity was respected with staff knocking on doors before they entered. Staff were observed to talk to service users in a friendly manner and there appeared to be very good relationships between staff and service users. A staff member was seen to be feeding a service user who needed this help and dealt with the service user in a calm, reassuring and friendly manner, at the service user’s pace. Both relatives spoken with also highly praised staff for their friendly care and welcoming attitude when they visited the home and said staff took care of their relatives health needs. Portland House DS0000061981.V310961.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users have the opportunity to lead full and active lifestyle and can generally exercise choice. EVIDENCE: Though there is a high level of service users with mental disabilities, the service users spoken with again said there were no rules, that they could go to bed and get up when they wanted, request additional baths etc. There are service user meetings though the last two were not recorded so information to service users on what had been discussed was limited – the Registered Manager said this would be carried out in the future. Service users again said that they were satisfied with the range of activities on offer and they liked it when staff had time to sit and chat with them. Some service users said they liked being outside and enjoying the garden, which they did on a regular basis during warm weather. All service users said that their visitors were made welcome by staff and their relatives took them out. Portland House DS0000061981.V310961.R01.S.doc Version 5.2 Page 14 The Registered Manager said that it was important that service users were able to do things for themselves, however small. Staff also confirmed this aim of the service. Service users all said they enjoyed the food and they had alternatives to all meals. Food records showed there were a variety of vegetables offered. The food tasted was found to be of a good standard with two choices of main meal and dessert. The homemade dessert tasted by the inspector was full of flavour. Service users said there were a number of activities – games, music, staff speaking to service users etc. The unused downstairs lounge has been converted to an Activities Room with games, colouring, reminiscence materials, exercise machines etc available – this situation is commended. Records confirmed service users participation in activities. The Registered Manager stated that the day trip to Skegness in August 2006 was enjoyed by service users and the feedback was so positive that a longer trip is to be organised in 2007. Portland House DS0000061981.V310961.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for receiving and responding to complaints are sound with good staff training provided, resulting in the protection of service users rights. EVIDENCE: Service users again said that they would have no hesitation about going to management if they had a problem and were confident it would be properly sorted out. There is a detailed Complaints Procedure, which meets the National Minimum Standard. The Registered Provider said there had been no complaints received since the last inspection and the Commission for Social Care Inspection has also not received any complaints. Staff members spoken to knew to take concerns further if abuse was suspected and were generally aware of outside Agencies to go to if no action was taken by the service. The Registered Manager is to emphasis to staff the role of the Commission for Social Care Inspection so that concerns can be passed on if necessary. A relative spoken to said that if there was anything of concern it would immediately be put right. Portland House DS0000061981.V310961.R01.S.doc Version 5.2 Page 16 Portland House DS0000061981.V310961.R01.S.doc Version 5.2 Page 17 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): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A comfortable, clean and homely standard of accommodation is provided for service users. EVIDENCE: Service users all said that they liked their bedrooms and they could bring in their own furniture. Facilities were found to be clean and odour free. Service users said that this was always the case and that rooms were always clean. Some bedrooms were inspected and found to be homely with great deal of service users own possessions in them, and organised the way service users wanted. Lounges were also homely and attractive. Facilities have been improved with regard to the ground floor corridor and toilet and heating installed in a WC. The Registered Manager said that it is Portland House DS0000061981.V310961.R01.S.doc Version 5.2 Page 18 planned to attend to paintwork to some toilet en suites and some outside windows. The Registered Manager stated that a new shower had been installed to a ground floor shower room though a floor-draining shower had not been installed to a first floor shower as no service users used this facility. However this remains a recommendation, as there is a disincentive to use a facility that is not fully accessible. A loop system to assist service users with hearing loss has not yet been installed. This remains a recommendation, as it will allow an improved service to those service users who need this in future. Portland House DS0000061981.V310961.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. At the time of inspection staff at the home were sufficient in numbers, and there are staff training and recruitment procedures in place to meet the service users needs. EVIDENCE: Staffing levels meet the Requirements of the Commission for Social Care Inspection in that there are three care staff for all daytime and evening shifts and two care staff available for night shifts. Records showed staff have generally received training regarding essential care issues though the Registered Manager recognised that some staff were in need of mental health training. A staff member said there is encouragement to enrol on National Vocational Qualification level courses. A record showed that another staff member had completed the National Vocational Qualification level 2 award. The Registered Provider stated that the aim of the service is to achieve the National Minimum Standard of 50 of staff with this training and is on course to do so with two further staff attending level 2 training. The staff records inspected were found to be generally satisfactory with references and Criminal Records Bureau/ Protection of Vulnerable Adults Portland House DS0000061981.V310961.R01.S.doc Version 5.2 Page 20 checks in place. The Registered Manager is to amend the staff Application form as it currently it does not allow an employment history to be recorded, which means that any gaps in employment history cannot be explored. Portland House DS0000061981.V310961.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management team generally effectively manages the home to protect the rights and needs of service users. EVIDENCE: Service users, relatives and staff said that they thought the home was well managed by the Registered Manager and service users and relatives said staff were good at their jobs. In terms of Quality Assurance, the Registered Manager uses a very detailed format, which she is working her way through at the moment. There is also a quality questionnaire, which is supplied to service users/relatives, to determine how the service is operating. The Registered Manager said survey results Portland House DS0000061981.V310961.R01.S.doc Version 5.2 Page 22 would be published in the Statement of Purpose to supply more information to interested parties. The Registered Manager keeps small amounts of service user monies - records are generally detailed with running balances, two signatures per transaction and receipts kept. One record was slightly behind in recording – the Registered Manager said transactions would be recorded immediately in future. Fire records showed that essential tests – fire alarms, fire drills etc had been carried out on a regular basis and the fire risk assessment for the home had been completed. Emergency lighting testing was slightly behind schedule – the Registered Manager said this would be followed up. Fire doors have approved enclosures fitted so that doors can be kept open whilst at the same time preserving fire safety. The Registered Manager stated that a new up to date fire alarm system has been purchased and installation was completed on 1/9/06. The water temperature was taken in a bathroom, which measured 37c from the bath, the National Standard being close to 43c. The Registered Manager said it took a long time for the water to get warmer but staff ensure that water is not tepid so that service users can enjoy their bathing. The inspector saw risk assessments for safe working practices – these are maintained to ensure that risk is managed and service users welfare protected. Portland House DS0000061981.V310961.R01.S.doc Version 5.2 Page 23 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 X 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 2 X X X X X X 4 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 4 X 4 X X X X 3 Portland House DS0000061981.V310961.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP8 Regulation 12 (1) Timescale for action Service users need to be referred 22/09/06 to medical authorities following a serious fall. Requirement 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 OP19 Good Practice Recommendations Residents would benefit from having a floor-draining shower on the first floor to make this facility more accessible. A loop system would assist residents with hearing difficulties. 2. OP19 Portland House DS0000061981.V310961.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Portland House DS0000061981.V310961.R01.S.doc Version 5.2 Page 26 - 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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