Inspection on 31/07/07 for Portland House

This inspection was carried out on 31st July 2007.

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

Portland House 29/07/09

Portland House 03/07/06

Portland House 17/11/05

Portland House 11/05/05

Portland House 02/12/04

Portland House 23/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Portland House 11 Portland Road Hove East Sussex BN3 5DR Lead Inspector Jennie Williams Key Unannounced Inspection 31st July 2007 10:10 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 DS0000014026.V343126.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 DS0000014026.V343126.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Portland House Address 11 Portland Road Hove East Sussex BN3 5DR 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) 01273-325705 01273 738260 manager.portland@vigcare.co.uk Mr Joginder Singh Vig Mrs Beant Kaur Vig Sunjay Sungkur Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Portland House DS0000014026.V343126.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. For a maximum of 36 service users in receipt of nursing care and 4 service users in receipt of personal care That one named service user is admitted under the age of sixty (60) years on admission Service users must be older people aged sixty five (65) years or over on admission. 18th December 2006 Date of last inspection Brief Description of the Service: Portland House is a care home registered for forty (40) places for people of either gender, aged sixty-five (65) years or over on admission. Thirty-six places are registered for people in receipt of nursing care and four places for people in receipt of personal care only. The home is located in a quiet residential area in Hove. Mr and Mrs Vig in Partnership are the registered providers, who own several care homes throughout the South of England, predominantly older people services. The home is a large detached home that provides accommodation over two floors. There is a lounge area on both floors of the home and a communal room in the basement that can be used if needed. There is a passenger shaft lift at the home to assist residents accessing all areas of the home. There are ramps or chair lifts in other areas for those unable to mobilise on steps. There are seven rooms for shared occupancy, of which three are provided with en suite facilities and twenty-two rooms for single occupancy, of which ten are provided with en suite facilities. The home generally accommodates only thirty-six people. Mr Vig has confirmed that the home continues to be registered for forty places as some of the larger single rooms are able to be used for double occupancy if a couple chooses to be accommodated together. There are suitable communal toilet facilities. There are two assisted baths and a wheel in shower on the ground floor and an assisted bath on the first floor. Four of the en suites have baths provided, however these are not assisted and are currently not suitable for use by the residents residing at the home. Weekly fees range from £273 to £600 per week. There are additional fees; hairdressing, chiropody and newspapers/magazines. This information was provided to the CSCI on the 25 June 2007. Prospective service users find out about the home through social service referrals and from living in the area. Portland House DS0000014026.V343126.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. It should be noted that following recent CSCI consultation, it was identified that service users prefer to be called people who use services. The Registered Manager confirmed that they use the term service users/residents. For the purpose of this report, people who use the service will be referred to as residents. This unannounced site visit took place over eight and a half hours on the 31st July 2007. Evidence obtained at this site visit and information that the CSCI have received since the last inspection forms this key inspection report. Six residents were spoken with throughout the inspection process. The Inspector had limited communication with some residents. Ten resident surveys were sent to the home to distribute prior to the site visit, of which none of these have been returned. One care plan was viewed and specific areas of care were looked at in a further six care plans. The Registered Manager and fourteen staff were spoken with throughout the site visit including: cook, laundry and maintenance people, two cleaners/housekeepers, deputy manager, a registered nurse and seven care workers. Five staff files were viewed and training records inspected. There was a residents/relative meeting being held on the day of the site visit and the Inspector was able to use this time to speak with seven visitors who had attended. Another visitor was also spoken with throughout the site visit. Two visiting health professionals were also spoken with. Ten relative/visitor surveys were sent to the home to display of which nine were returned. A tour of the environment was provided and some individual rooms were viewed, with the resident’s permission. Medication procedures were inspected. The quality assurance system was discussed and complaint and Safeguarding Adult records were viewed. Copies of the staff rota and menus were viewed. An Annual Quality Assurance Assessment (AQAA) was sent to the home prior to the site visit. This was to obtain information about the establishment to assist CSCI in the inspection process. Health and safety records were not viewed as this information has been provided in the AQAA. There were thirty-four residents residing at the home on the day of the site visit. Portland House DS0000014026.V343126.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? A random unannounced inspection has been undertaken between the last key inspection and this key inspection. This was to ensure compliance had been made with the requirements made at the last key inspection. Improvements made have been judged from requirements made at the random unannounced inspection. The privacy, dignity and confidentiality of service is maintained and promoted as required at the last inspection. Two requirements made at the last inspection was regarding the provision of hot water. The Registered Manager confirmed that there was a problem with the boiler, which has now been replaced. Water temperature is tested monthly to ensure that hot water continues to be dispensed at the recommended temperature. Portland House DS0000014026.V343126.R01.S.doc Version 5.2 Page 7 It was required that the provider addresses the management ethos within the home. The Registered Manager confirmed that he is strict and staff confirmed that he is strict in his management methods, but is fair. There were no concerns identified at this site visit regarding the management ethos. Most staff confirmed that they are happy working at the home. Any recommendations made at the last inspection have been looked at and appropriate action taken if identified. 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. The summary of this inspection report can be made available in other formats on request. Portland House DS0000014026.V343126.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 DS0000014026.V343126.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5 & 6. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has information available for prospective residents/representatives on the facilities and services provided to make an informed decision if their needs can be met at the home. The pre admission process ensures that only residents whose needs can be met at the home are admitted. EVIDENCE: The home has a Statement of Purpose and Service Users Guide that provides prospective residents with information regarding the services and facilities provided at the home. The Registered Manager confirmed that these documents are going to be updated and made available in different formats. The pre admission assessment viewed demonstrated that the needs of the individual can be met, however it was discussed with the Registered Manager that these assessments could be expanded. The Registered Manager or a Portland House DS0000014026.V343126.R01.S.doc Version 5.2 Page 10 registered nurse will undertake the pre admission assessments of any prospective resident. No requirement or recommendation has been made in relation to pre admission assessments as the Registered Manager confirmed that he will be reviewing the assessment forms. The Registered Manager confirmed that there was no one residing at the home from any minor ethnic community, social/cultural or religious groups with any specific needs or preferences. Two residents have limited English communication, however staff are familiar with these peoples communication methods and family members are involved in assisting the home to communicate when medical attention is required. It was confirmed that the family have been encouraged to bring in cultural food for these individuals, however no specialist diet is required. It was noticed on the pre admission assessments that people are asked if they have a preference to the gender of the carers that will provide personal care to them. The Registered Manager confirmed that these forms are being amended to ensure that information is obtained regarding an individual’s sexuality and religious belief. Of the residents that were asked, all confirmed that they felt their needs were being met at the home. Staff spoken with confirmed that there are some residents with high dependent needs, however feel that all residents are appropriately placed and all needs are able to be met with the number and skills of staff on duty. Some residents spoken with confirmed that they or a representative had visited the home prior to moving in. The manager confirmed that prospective residents are encouraged to visit the home before moving in. All surveys received from relatives/visitors identified that they always receive enough information from the home to help them make decisions. The home does not have dedicated accommodation to provide intermediate care. Respite care is available if there is a spare place available. The home prefers not to take emergency admissions. Portland House DS0000014026.V343126.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being met with the information provided in the care plans on the assessed needs of residents. Residents are generally safeguarded by the medication procedures in place. Residents’ privacy and dignity are respected. EVIDENCE: Care plans were not viewed in detail at this site visit, as there were no shortfalls identified at the last inspection. Care plans viewed provide guidance on how to meet the assessed needs of individual residents. Care workers spoken with confirmed that the registered nurses draw up and review the care plans and they contribute verbally to this process. Care workers do not always read care plans and rely on the registered nurses to keep them informed of changes in any needs. Some carers expressed that they are not involved in the handover between nurses Portland House DS0000014026.V343126.R01.S.doc Version 5.2 Page 12 and feel that they are sometimes not kept fully informed. This was confirmed by relatives/representatives spoken with that when they ask a staff member a question about events that may have occurred with their friend/relative, the staff are not always able to answer their queries and have to find a nurse to advise. This was also evident when a visiting health professional visited the home to assess an individual. They discussed with the Registered Manager that the staff member spoken with was unable to answer any of the questions pertaining to the individual. Some care workers expressed that they would like be involved in the care plans more and to be involved in the handover of residents needs so that they have the full picture of individual needs. The Inspector raised the query that with the residential people residing at the home why they needed the registered nurses to input into their care. The Registered Manager took this feedback on board and will discuss this issue with staff at the next meeting. Relatives/visitors spoken with confirmed that they are provided with an opportunity to be involved in developing and reviewing care plans of the their friend/relative and are overall satisfied with the care provided at the home. Residents spoken with confirmed that all their needs were being met at the home. Care plans are typed up and staff are writing the monthly reviews on additional forms. It was discussed with the Registered Manager that there is a risk of information being lost if the typed care plans are not amended at the time of changing needs. Staff have to read through months of reviews to identify clearly what changes have been made. This is not reflected as a requirement or recommendation as the Registered Manager confirmed that he will address this with nurses. One care plan had conflicting information in it regarding the continence of a resident. One care plan demonstrated that this individual had an indwelling catheter in situ and another care plan was in place for urinary incontinence and to prompt the individual to regularly use the toilet. This was pointed out to the Registered Manager who confirmed that he will address this and ensure all care plans have up to date information in them. There is documentation in place regarding the dressing of wounds. Nurses are writing what materials are used for the dressing but are not writing a description of the wound to identify that the dressings in place are effective. This was discussed with the deputy manager at the site visit and reiterated to the Registered Manager the following day during feedback. There was evidence that advice is sought from the tissue viability nurse when the need arises. Care plans are kept on an open shelf near the nurses’ station. It was discussed with the Registered Manager that consideration be made to securing Portland House DS0000014026.V343126.R01.S.doc Version 5.2 Page 13 these documents to ensure confidentiality remains promoted. The Registered Manager confirmed that it has never been an issue with people accessing these files, however will discuss this issue with the staff. A visiting health professional spoken with confirmed that the home is proactive at seeking advice when the need arises. One health professional visiting the home was visiting for the first time and was unable to comment about the practices within the home. The Registered Manager confirmed that advice is sought from health professionals when needed such as speech and language therapist and dietician etc. Medication administration records (MAR) charts viewed evidenced that medication is being signed for at the time of administration. Registered nurses administer all medications. It was discussed with the registered nurses on duty that as a good practice recommendation all hand written prescriptions are double signed by two staff who are medication trained to reduce the risk of errors occurring. Any hand written amendments must be signed to identify who has made the amendments. Where medication is prescribed as one or two tablets, the staff are not regularly recording how many they are administering at the time. Some creams/tablets were prescribed for twice per day. Staff were only signing that this was administered once. MAR charts should be updated to reflect actual practice and only changed on advice from the GP. It was confirmed that individuals with prescribed creams have a care plan in place and also information is kept within the individual’s rooms. Controlled drugs were observed to be stored securely and accurate records are maintained. Medication was confirmed to be disposed of through a licensed company as per legislative requirements. There was no one self-medicating on the day of the site visit, however the Registered Manager confirmed that individuals are provided with this opportunity if they wish following a risk assessments being undertaken. Staff were observed to have a good professional rapport with residents and were heard to be calling them by their preferred term of address. Residents spoken with felt that staff respect their privacy and dignity. A written comment from a relative/visitor stated what the care home does well is ‘the way it treats patients with respect and dignity’. Portland House DS0000014026.V343126.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ lifestyle within the home is their own choice and residents are provided with sufficient stimulation to fulfil their interests and needs. EVIDENCE: Residents spoken with felt that there were sufficient activities provided at the home that are within their interest and ability. There is an activities coordinator employed at the home for 15 to 20 hours a week. Staff spoken with felt that sufficient activities were provided for residents. One written comment from a relative/visitor was that the care home could improve by ‘more outings’. Another written comment was ‘activities and grooming seem to make the residents feel involved and cared for. Well done!’. Relatives/representatives spoken with confirmed that there are no restrictions for visiting the home and that they are always made welcome. Residents are able to receive their visitors in private. Portland House DS0000014026.V343126.R01.S.doc Version 5.2 Page 15 Six relative/visitor surveys received demonstrated that the home always assists an individual to keep in touch with them. Three identified that this was not applicable with their relative/friend as they visit regularly or the health needs of the individual do not make it possible for them to keep in touch. Residents are provided with a choice in meals and were complimentary about the food provided at the home. The lunchtime meal was observed to be enjoyed by residents. It was observed that one staff member assisting an individual was standing over a resident when feeding them and there was no communication at all. This was addressed with the individual on the day of the site visit. Other staff were observed to be offering discreet assistance to those who required help with feeding. The cook has been working at the home for over 20 years and devises the menus for the home. Menus viewed demonstrated that there are choices available and a varied diet is provided. The cook is familiar with the residents preferences in food, however it is recommended that a list be kept in the kitchen of residents likes/dislikes/allergies in relation to food should this person be ill and a temporary cook is required. The cook confirmed that Environmental Health undertook an inspection of the facilities about three months ago. There were some shortfalls noted and it was confirmed that all of these have been addressed. The Inspector did not view this report. Portland House DS0000014026.V343126.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents/representatives feel comfortable to complain, reassuring them that they are being listened to and that action will be taken, if necessary. Safeguarding Adult procedures and the training of staff ensure residents are safeguarded. EVIDENCE: There is a complaints procedure provided at the home that all people have access to. The AQAA and records observed identified that there have been two complaints made to the home in the last 12 months. Records identify what action was taken to address the concerns raised. The complaints related to poor communication and one was regarding the lack of clothes an individual was wearing. Both complaints were substantiated and appropriate action taken to resolve the issues identified. Six relative/representative surveys identifies that they know how to make a complaint, one did not know how to complain and two cannot remember if they were provided with information on how to complain. All surveys demonstrated that appropriate action is always taken when they have raised any concerns with the home. Of the residents that were asked, they know how to raise a complaint and feel comfortable to do so. Portland House DS0000014026.V343126.R01.S.doc Version 5.2 Page 17 One resident expressed to the Inspector that the only concerns they had was that their call bell is not answered at night time. The resident also informed the deputy manager on duty who ensured that she would look into this and address it with the night staff. There are procedures in place for Safeguarding Adults. The content of these were not read. Staff confirmed that they have received training on the Protection of Vulnerable Adults (POVA). There have been four Safeguarding Adults alerts made in the last twelve months. One related to the care of a resident, two were around manual handling practices of the staff and inappropriate use of equipment and one alert not related to the practices or care provided at the home. One was inconclusive and the manual handling incidents were substantiated. One investigation is ongoing. The Registered Manager confirmed that action was taken following the outcome of these Safeguarding Adults investigations. This included following the home’s disciplinary procedures and the retraining of staff in manual handling and POVA. The Registered Manager has been proactive and has obtained information on the changes in the Mental Capacity Act and has been providing this information to relatives/representatives. The AQAA identifies that they are aware that this is an area that they could do better in and is taking action to address this. Portland House DS0000014026.V343126.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and homely environment and are provided with suitable indoor and outdoor communal facilities. EVIDENCE: Rooms observed were noted to be personalised to reflect the individual’s choice and character. Residents spoken with confirmed that they were happy with their rooms. Rooms are located over two floors. There is a passenger shaft lift at the home that provides access to all areas of the home. There are ramps or chair lifts in other areas for those unable to mobilise on steps. Portland House DS0000014026.V343126.R01.S.doc Version 5.2 Page 19 There are four assisted bathing/shower facilities located at the home for communal use. Four rooms have baths provided in the en suite facilities, however are not assisted facilities and are not suitable for use with the current residents residing at the home. Consideration should be given to making these facilities useable. It was observed that a couple of residents were in their rooms without their call bells within reach. This was discussed with the Registered Manager, who confirmed that some are unable to use this facility. It was advised that documentation is put in place to evidence this. The Registered Manager confirmed that residents are provided with locks to their own rooms if they wish, based on a risk assessment being undertaken. There is a balcony/conservatory area that residents can enjoy. There is a garden at the rear of the building, however this is not easily accessible to residents. The Registered Manager and deputy manager confirmed that there are plans to address this. It was discussed with the deputy manager that consideration be made to having raised garden beds that will allow easy access for residents to use. The AQAA identifies that making the rear garden accessible to residents, if financially viable, is an improvement they plan to undertake in the next 12 months. A representative/relative informed the Inspector that wheelchairs need to be maintained as they found it difficult when taking their relative out. They were going to address this with the Registered Manager themselves. The Registered Manager confirmed that the hospital provides maintenance for the wheel chairs. The person responsible for the laundry services confirmed that they have sufficient equipment to undertake their duties and that the washing machines are provided with a sluice cycle for soiled linen. The AQAA identifies that all staff have received training on the prevention of infection and management of infection control. There were no offensive odours noted on the day of the site visit. Relatives/representatives spoken with confirmed that they found the home to be clean at all times that they visit. The Registered Manager confirmed that there are procedures in place for the disposal of clinical waste. There were no offensive odours noted on the day of the site visit. The cleaners/staff must ensure that the underneath side of bath hoist seats are regularly cleaned. A written comment from a relative/visitor stated ‘Cleanliness is very good’. Portland House DS0000014026.V343126.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being met with the skill mix of staff on duty and are generally safeguarded by the recruitment procedures in place. EVIDENCE: Staff spoken with confirmed that there were generally sufficient numbers of staff on duty to meet the needs of individuals residing at the home. Relatives/representatives and some residents expressed to the Inspector that they did not feel there were enough staff on duty. They were happy to address these concerns with the Registered Manager at the relative meeting being held on the day of the site visit. Some staff commented that they could do with an additional carer to work between the floors at nighttime. The Registered Manager confirmed that he ensures that staffing numbers are kept under regular review. There is a registered nurse on duty at all times. Some comments written on relative/visitor surveys regarding the staff were: ‘Majority of staff are very hard working and pleasant’, ‘very cheerful and helpful’, ‘seem genuinely caring’, ‘there is a continuity of staff, which I feel builds up a good relationship between them, my relative and with myself’ and ‘I am very satisfied with the service provided and I am thankful to all members of the staff from the manager to the cleaner’. Portland House DS0000014026.V343126.R01.S.doc Version 5.2 Page 21 There are ten care workers employed at the home. One has achieved their National Vocation Qualification (NVQ) level 3, two have NVQ level 2 and two are currently undertaking NVQ level 2 studies. All other care workers are from overseas and are registered nurses in their own country, working in the capacity of care workers in the UK. Staff files viewed demonstrated that there are generally good recruitment practices followed. Ensuring application forms are fully completed will assist in addressing any shortfalls, particularly in relation to having clear employment histories and dates. The AQAA identifies that all people who have worked in the home in the past 12 months had satisfactory pre-employment checks. The Inspector was informed that the Registered Manager proposes to ask residents if an individual wishes to be involved in the recruitment process of new staff. There was not clear evidence for one worker on the eligibility to work in the UK. It was confirmed following the site visit that this person is able to work in the UK. It was discussed with a representative of the company on the day of the site visit that evidence must be provided in the individuals file on their eligibility to work. Of the staff that were asked, they all confirmed that they felt their recruitment was done fairly. Staff spoken with confirmed that they are provided with suitable training opportunities and recent training undertaken included: manual handling, first aid, fire training and POVA. Registered nurses confirmed that they are provided with additional training relevant to their roles. The Registered Manager confirmed that palliative care training is ongoing and there is a training programme in place. Evidence of training provided was noted to be in individual staff files. Where training may be out of date, the Registered Manager has already noted this and action is being taken to address the shortfall. Previously the home had their own induction programme for new staff. The Registered Manager confirmed that he has received information on the Common Induction Standards as set by the Skills for Care. It was confirmed that all new staff employed at the home will undertake this induction and foundation programme. Portland House DS0000014026.V343126.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff and residents benefit from a well managed home and the quality assurance system in place ensures the home is run in the best interest of residents. The health, safety and welfare of residents and staff are promoted and protected so far as is reasonably practicable. EVIDENCE: The Registered Manager has been working at the home since March 2003. He is a registered nurse who confirmed that he has current registration with the Nursing and Midwifery Council (NMC). He has had approximately ten years experience in management within the healthcare industry. He has NVQ level 4 in care and has completed the Registered Manager Award course. He Portland House DS0000014026.V343126.R01.S.doc Version 5.2 Page 23 confirmed he is also a NVQ assessor. Staff spoken with confirmed that they found the Registered Manager generally to be supportive and approachable. Of the staff that were asked, all confirmed that there are clear roles and responsibilities within the home. Staff confirmed that they do not have any dealing with the registered provider or any external management. There is a quality assurance and quality monitoring system in place that assists to ensure that the home is run in the best interest of residents. Residents/relative/representative meetings are held every three months and staff meetings are regularly held. A written comment on a relative/visitor survey was ‘we are invited to meetings where we can voice our opinions and concerns’. It was confirmed that feedback is sought from other stakeholders on an annual basis. Any issues are discussed with staff on a one to one basis during their appraisals. There is a suggestion box located at the home where anyone involved with the home can offer suggestions/comments anonymously. The Registered Manager confirmed that the analysis of any surveys is shared during meetings and action is taken to address any issues. The results of the last quality assurance surveys were not viewed. It is an outstanding requirement that the Registered Provider undertakes Regulation 26 visits and prepares a report for the manager, to ensure they are made aware as the responsible person that the service is meeting its legislative requirements. The expectations and content of these reports were discussed with the Registered Providers at a previous meeting with CSCI representatives. The AQAA identifies that the proprietors are up to date with their monitoring of the home, however evidence shows that this is not the case. The Registered Manager confirmed that he has not received any monthly report from the Responsible Individual. The home does not hold any personal allowance for residents. It was confirmed that residents hold their own monies or have their own arrangements in place. Health and safety records were not viewed. Staff confirmed that they have received fire training and that regular fire drills are undertaken. The AQAA identifies that equipment in use has been tested or serviced as recommended by the manufacturer or other regulatory body and that all relevant policies and procedures are in place. Portland House DS0000014026.V343126.R01.S.doc Version 5.2 Page 24 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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 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 3 X 2 X 3 X X 3 Portland House DS0000014026.V343126.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Timescale for action The registered person shall make 31/08/07 arrangements for the recording, handling and safe administration of medicines received into the care home to ensure medication is administered as prescribed. That the Registered Provider 31/08/07 undertakes Regulation 26 visits and prepares a report for the Registered Manager, to ensure they are made aware as the responsible person that the service is meeting its legislative requirements. (Timescale 30.01.07 not met.) Requirement 2. OP33 26 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 OP8 Good Practice Recommendations That descriptions of the wounds are recorded when DS0000014026.V343126.R01.S.doc Version 5.2 Page 26 Portland House 2. OP9 dressings are changed to evidence that the dressings in use are providing effective treatment. That all hand written prescriptions are double signed by two staff who are medication trained and that any amendments are signed by the person making the changes. Portland House DS0000014026.V343126.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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