Inspection on 10/08/06 for Portland House Care Home

This inspection was carried out on 10th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Portland House Care Home 05/11/08

Portland House Care Home 12/01/06

Portland House Care Home 12/09/05

Portland House Care Home 24/02/05

Portland House Care Home 15/09/04

Portland House Care Home 16/02/04

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

CARE HOME ADULTS 18-65 Portland House Care Home 113 & 146 Portland Road Nottingham NG7 4HE Lead Inspector Joanna Carrington Key Unannounced Inspection 10th August 2006 10:00 Portland House Care Home DS0000002240.V307604.R01.S.doc Version 5.2 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 Care Home DS0000002240.V307604.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 Adults 18-65. 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 Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Portland House Care Home Address 113 & 146 Portland Road Nottingham NG7 4HE 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) 0115 978 7840 0115 978 9995 Networking Care Partnerships (SW) Ltd Ms Catherine Moir Care Home 27 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (27) of places Portland House Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 Brief Description of the Service: Portland House Care Home is registered to provide accommodation and care for up to twenty-seven younger adults with mental health needs. There are currently twenty-two service users at the home and although the home is currently registered for twenty-seven places there are in fact only two vacancies. Two bedrooms initially used as double rooms are now single rooms and a very small bedroom is now being used as the medication room. The registration of this service therefore must be changed. The home consists of two units situated on opposite sides of Portland Road. Portland House is the larger home and Hemsley House is a smaller unit that provides an environment and support to four service users as a step towards independent living. The home is situated in a residential area close to Nottingham City Centre, and has access to public transport (including a tram service). Shops, parks, and pubs are within easy walking distance. Portland House provides spacious accommodation for residents who are mobile. The fees for living at Portland House at the time of the inspection are £340.96 per week. Portland House Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over eight hours on 10th August 2006. This was the home’s key inspection for this inspection / financial year. The main method of inspection was called ‘case tracking’ which meant selecting three service users and tracking the care and support they receive through checking their records, observation of care practice and discussion with them and with staff. Staff records were looked at and a partial tour of the premises also took place in order to assess environmental standards. Altogether four service users and one staff member was spoken with. The registered manager was available for discussion and feedback throughout the inspection. What the service does well: Prospective service users needs are assessed before they move to the home and the staff team conduct their own assessment when a service user is admitted, which identifies needs and personal goals. Prospective service users have the opportunity to visit the home before deciding to move there. Service users are involved in developing and reviewing their care plan and are supported in being independent and in control of their own lives. Service users spoken with said that they come and go as they please and spend their time as they wish. The rights and responsibilities of service users are respected. Staff were observed treating service users with dignity and respect and interacting with service users in a positive and meaningful manner. Staff will help service users to initiate or maintain contact with family and friends, who are welcome to visit the home. The healthcare needs of service users are met by ensuring they access primary healthcare services including going to the dentist regularly and opticians. Some changes to staffing now means service users that need some support with attending appointments can have a staff member accompany them. There is a complaints procedure at the home which all service users are aware of. Service users spoken with confirmed that they feel comfortable enough to raise any concerns or complaints they may have with the manager. The necessary checks are carried out before a new staff member commences employment, which ensures that service users are protected and service users benefit from a staff team that receive all the appropriate training and support in order for them to carry out their jobs. There are good systems in place for monitoring the quality of care including ways that seek the views of service users. This ensures the home is run in their best interests. Portland House Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Portland House Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4 Quality for this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Without a Statement of Purpose specifically for Hemsley House, there is not enough written information to enable prospective service users to make a choice about where to live and to ensure the service is suitable in meeting their needs. Prospective service users’ needs and aspirations are assessed, but there have still been some admissions that the home is not registered for. EVIDENCE: Of all three service users’ case tracked there was evidence of a comprehensive assessment carried out by the staff team on their admission. Prior to admission the placing authority’s community care assessment is obtained in order to initially decide whether the home is suitable in meeting an individuals’ needs. Two of the three service users case tracked are supported by the Community Learning Disability Teams. Their assessments clearly state that they have both a learning disability and mental health needs. What the assessments don’t state is whether their mental health difficulties are their primary need, for which the care home provides the necessary support. Without this information this indicates that these service users have been placed out of the category of the care home’s registration. Portland House Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 9 All service users that are supported by the Community Learning Disability Teams must be re-assessed in order to confirm what is their primary need and to ensure that the home is suitable in meeting their needs. If their primary need is their learning disability then a variation to the registration is required. If the primary need of service users is their learning disability the registered provider must consider whether the home is suitable in terms of their vulnerability, particularly in the light of a current safeguarding adults investigation. (Please see Complaints and Protection section.) The small home across from Portland House, known as Hemsley House provides a different level of support to Portland House. The service aims to be a step towards independent living and service users that live there have minimal staff support, cook their own meals and have more control over their lives. Currently, there is not a Statement of Purpose for this service. To ensure that prospective service users and their relatives / representatives know enough about what this service provides a Statement of Purpose must be developed. (Please see the Staffing section later on in this report). Service users spoken with said that they had the opportunity to visit the home before they moved in and have their own copies of the Service User Guide. One service user said that they found this very useful especially the part on house rules. Portland House Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality for this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users know their needs and goals are reflected in their personal care plan and service users are supported to make decisions in their lives and to take acceptable risks. EVIDENCE: All four service users spoken with know who their key worker is and said they have spent time with their key worker going through their care plans and talking about their support. It is best practice for service users, where possible to sign their care plans as further evidence of their involvement and to confirm their agreement. This is a recommendation in the report. There was evidence on care plans that these are regularly reviewed, to ensure that any changes in needs and support is identified. A service user living at Portland House said he “can do what he wants to do” and another service user living at Hemsley House stated how he “can get on with his life”. It was evident from observation that staff respect service users choices for example, if they wish to spend time on their own at home or make plans to go out during the day. Service users manage their own finances Portland House Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 11 unless they request or accept assistance if they are having problems budgeting. All three service users case tracked have risk assessments in place that are relevant to their needs and lifestyle choices such as smoking, cooking and selfmanagement of Diabetes and monitoring health complications. Service users spoken with clearly value their right to independence. Portland House Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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, 15, 16 and 17 Overall quality for this outcome area is good. This judgement has been made using available evidence including a visit to the service. The rights and responsibilities of service users are promoted and upheld, including the right to maintain contact with family and friends. Service users are a part of the local community but support in accessing and providing activities is very limited. Service users are offered a varied and healthy diet but reviewing menus will ensure that mealtimes are enjoyed more. EVIDENCE: It was noted how some service users have very structured days going to college or doing voluntary work etc. Unfortunately the nearby drop-in centre has now closed, which was accessed by some service users. Although it is accepted that some service users choose to be independent and occupy their time themselves, which was pointed out in one of the returned service user surveys, in six of the eleven surveys returned it states there are never activities arranged by the home and another two surveys said only sometimes. Portland House Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 13 The activities co-ordinator post of eight hours per week is currently vacant and the registered manager reported that she is trying to recruit to this post even though in the past activities offered have not been taken up. More opportunities to go out with staff was raised by service users spoken with therefore it is recommended that further consultation takes place with service users on how to offer activities more effectively. Service users spoken with talked about going out to meet or visit their families and friends or they visit them at the home. They can ring family and friends in private. A staff member spoken with explained how support has been given to some service users to re-initiate contact with family. It was evident from observation and discussion that the rights and responsibilities of service users are respected and upheld. Staff were observed knocking on bedroom doors before entering and interacting with service users in a respectful and meaningful manner. A service user spoken with confirmed that staff treat him with dignity and respect. Service users have keys to their bedrooms for their privacy and so they can keep their possessions secure. It is recommended that where service users have responsibilities for domestic tasks and are being supported to develop daily living skills that this be incorporated into a relevant care plan. On the day of the inspection for lunch service users had a choice of omelette or hot dogs and rice pudding for desert. The evening meal was savoury mince with creamed potatoes, carrots and broccoli. There are always two options available to service users and a vegetarian meal is provided to the one vegetarian service user living at the home. The menu plan shows that there is a range of fish, meat and vegetable dishes but there is every week at least two occasions when chips are served. Although this may be the preference of the majority of service users it is recommended that healthier alternatives be offered to service users. In Hemsley House service users buy their own food and are supported to cook their own meals, something, which the service users spoken with are very proud of. Social Services raised concerns regarding unmet dietary needs of one service user and as a result a record was being kept of their meals and foods and fluid intake. This record has now stopped but a care plan has been implemented on assisting the service user with a food shopping list. Unless a written risk assessment confirms that service users are able to manage buying food and preparing meals without any detriment to their health and wellbeing, staff should support service users in this area and it is recommended, keep a record of meals consumed, in accordance with Regulation 17 of the Care Home Regulations 2001. Portland House Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality for this outcome area is good. This judgement has been made using available evidence including a visit to the service. The health and personal care needs of service users are generally met but some improvements to medicine management will protect service users and also promote good health. EVIDENCE: Appointment records held on individuals’ files show that relevant health and social care professionals such as community psychiatric nurses, community nurses and social workers are involved in the support of service users when appropriate and necessary healthcare checks such as dentist and opticians are attended. Some service users are independent in managing their health and will organise and attend GP appointments and other primary healthcare services themselves. For others there are arrangements in place for supporting them in arranging and attending their healthcare appointments. For one service user case tracked it identified on their assessment that prompting to have showers is needed, however there was no mention of helping the service user to be independent in this area in their care plan. The support may only be very slight but if staff are unaware of doing this and how to do this consistently and sensitively then there is a risk of deterioration in this individuals’ hygiene and self-care. Portland House Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 15 Medicines are stored securely in a walled cabinet, which is then locked in a special medication room. Medicines were well organised and the procedure staff must take if an administration error has occurred is available in the medication administration record (MAR) file. There are letters from doctors accompanying MAR records stating the length of time it is acceptable for a dose to be administered before the next dose is due. This then provides some flexibility with when medicines are given if service users are out or are up late for breakfast etc. For a service user that self-administers their inhaler a risk assessment was seen on the file, which ensures that the service user can manage this task independently and safely. Although MAR charts contain clear instructions for the administration of medicines and there is always an explanation using the relevant code why certain doses have not been administered this shows too many occasions when service users are either out or have refused to take their medication. This included a service user that was case tracked. There was no risk assessment in place specifying when and what action should be taken, for example inform the psychiatrist / psychiatric nurse, if they continually refuse their medication, which results in a deterioration in their mental health. For best practice and to ensure staff are fully aware of what action to take it is recommended that a copy of the devised risk assessment is also held on the MAR file. The quantities recorded on the MAR chart for one of the drugs audited did not tally with how many tablets were found in the cupboard therefore there was drugs unaccounted for. When this happens it is not possible to check whether all drugs signed as administered have actually been given. For the purposes of stock control and to audit that drugs are being administered as prescribed an accurate record of the quantity of drugs in the home is required. The most efficient way of doing this is to carry over any remaining tablets from the previous cycle onto the next MAR chart. There was a ‘when required’ drug found in the cupboard for one service user that has not been recorded on the MAR. This is required. Portland House Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality for this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users feel their concerns and complaints are taken seriously and acted on. The home aims to protect service users from abuse however further action in accordance with the local policy and procedures should be taken to assure this is the case. EVIDENCE: The home has a Complaints Procedure, which is printed in the service users’ guide, and also displayed in the entrance to the home. All service users spoken with are aware of the complaints procedure and said they would have no hesitation in complaining if they felt they needed to. There have been no complaints made since the last inspection. Since the last inspection two service users currently have in situ Safeguarding Adults investigations concerning them. One of the service users’ has disclosed allegations about a family member and fellow service users at the home. Notifications to the Commission and the Adult Protection Unit were made in respect of these allegations and the Nottinghamshire Committee for the Protection of Vulnerable Adults (NCPVA) Policy and Procedures have been followed appropriately; both Social Services and the Police are involved in the investigation. There have been no outcomes as yet because the Police have not completed their investigation. The service user is receiving multidisciplinary support during this difficult time and the necessary action was taken when the disclosures were made to protect the resident from abuse. Portland House Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 17 The Safeguarding Adults investigation concerning the other service user was invoked following referrals from social care professionals. These referrals concerned a staff member at the home. Social Services notified the Commission of the investigation and the pending strategy meeting. It came to light at the inspection that this meeting was the second strategy meeting / case conference, to discuss findings of the investigation and to identify further action. At the time the NCPVA procedures were invoked the registered manager should have notified the Commission in accordance with Regulation 37 of the Care Home Regulations 2001. Social Services passed on concerns to the Commission about the staff member not being suspended from duties when the alert was raised. At the inspection the registered manager reported that this action was not taken following legal advice. In the interest of service users’ protection safeguarding adults procedures should override disciplinary procedures therefore suspending the service user would have been the appropriate action to take. The investigation has now been closed with necessary action identified. There was evidence seen that this action has commenced. Further care plans have been implemented for the service user and records of supervision and counselling were seen for the staff member. Due to evidence that improvements are already being made and that the procedures were correctly followed for the other service user this outcome group overall has been assessed as good. Portland House Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality for this outcome area is good. This judgement has been made using available evidence including a visit to the service. The environment is clean and hygienic and service users will also benefit from a homely and comfortable environment once all of the refurbishment work has been completed. EVIDENCE: On a tour of the premises it is apparent that the environment is kept clean and hygienic. There are industrial washing machines in the laundry room and the facilities are appropriate to the needs of residents. Service users can wash their own laundry with the assistance of staff. All communal areas of the home have recently been redecorated and service users have chosen to have laminate flooring in the hallway and smoking lounge. New furniture has already been purchased for the lounge but is not yet in use until the carpets have been purchased and laid. Evidence of quotations for carpets was provided and the registered manager believes this will be completed very soon. The carpets throughout the home were observed to be very worn and stained and are certainly in urgent need of replacing. Portland House Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality for this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are protected by the home’s recruitment practices and service users benefit from a staff team that are trained and supported in meeting their needs. Staffing levels however must be reviewed to ensure they are appropriate in meeting the needs of service users. EVIDENCE: A staff member spoken with confirmed that training opportunities are good and that as well as attendance of mandatory courses there is also specific training relevant to the individual and collective needs of service users. Training records of three staff were examined and showed they have received internal training in Health and Safety, Food Hygiene, Moving and Handling Fire Safety and Residents’ Welfare. Courses on Mental Health Awareness and Learning Disability Awareness and de-escalation techniques are also accessed. The staff member said they feel supported by the manager and on staff files there were copies of supervision records. There was also evidence of two written references and a Criminal Record Bureau disclosure on three staff files looked at. In Portland House there are two support staff on at all times for sixteen service users and in Hemsley House there is one support staff available for four service Portland House Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 20 users. Social Services have recently expressed concerns over staffing levels not meeting the needs of service users in Hemsley House. In response to this the registered manager has implemented a system in which there is now an hour’s overlap in the middle of the day to enable service users to be supported to healthcare appointments and going out in the community. Two service users living in Hemsley House were case tracked and spoken with. Both are very proud of the level of independence they have but did comment on how they wish staff could go out with them more in the community. Due to the current increased vulnerability of one service user this service user needs to be accompanied when going out in the community particularly when withdrawing money at the bank. One hour’s overlap is very restrictive when this level of support is required. Without a Statement of Purpose for Hemsley House, which outlines the philosophy of the service, level of support, facilities and services offered then this is not adequate in ascertaining whether service users being admitted to the home meet the criteria for the service. The needs of service users living at Hemsley House must be reviewed to ensure that staffing levels are appropriate and as a result staffing levels amended accordingly. Portland House Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality for this outcome area is good. This judgement has been made using available evidence including a visit to the service. The health, safety and welfare of service users are promoted and protected. The home is well run and systems for monitoring the quality of care are in place, to ensure the home is run in the best interest of service users. EVIDENCE: The overall outcomes of this inspection demonstrate that the home is well run. Staff spoken with described the registered manager as being approachable and supportive. Since the home has joined a new provider there are new systems for quality assurance and monitoring in the process of being implemented. There are various self-audits undertaken in the home. There is a monthly audit that covers all aspects relating to quality of service provision and standards including medication, health and safety and financial audits. Every year feedback surveys are sent out to service users and is then used to identify any developments or improvements to the service. Portland House Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 22 The fire log shows that all necessary fire safety testing and drills have been carried out and there are measures in place for the prevention of Legionella. There are risk assessments for the environment and safe working practices and all substances hazardous to health are stored securely. Portland House Care Home DS0000002240.V307604.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 Adults 18-65 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 1 2 2 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 1 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 X 3 X X 3 X Portland House Care Home DS0000002240.V307604.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 YA1 Regulation 4, 5 Requirement Timescale for action 01/10/06 2. YA2 14 3. YA23 37 4. YA33 18 Develop a Statement of Purpose and Service User Guide for Hemsley House, including all information as specified under Schedule 1 of the Care Home Regulations. 10/11/06 Refer the service users supported by the Community Learning Disability Teams for reassessment of their needs to ensure that their individual needs are being appropriately met and to ascertain whether their learning disability or mental health is their primary need. If service users’ primary need is their learning disability then an application for the variation of registration must be made. Ensure any event in the care 10/08/06 home which adversely affects the well-being or safety of any service user is notified to the Commission. This refers to any time when the Safeguarding Adults procedures are invoked. Review staffing levels in Hemsley 01/10/06 House to ensure they are appropriate to the needs of service users. Portland House Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 25 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. 4. 5. Refer to Standard YA6 YA13 Good Practice Recommendations Add signatures of service users to care plans to evidence their involvement. Consult with service users over the provision of activities and community access and whether or not the appointment of an activities co-ordinator will provide this. For service users receiving support on developing daily living skills and have responsibilities for domestic duties record this in a relevant care plan. Offer a healthier alternative meal to service users. Devise risk assessments for service users that are independent with buying food and preparing meals, to identify any support that may be necessary for ensuring their dietary needs are met and where any form of support is necessary keep a record of meals prepared and eaten. Ensure a care plan is generated when a need has been identified in a service user’s initial assessment. Ensure any remaining drugs from the previous cycle are carried over on the next medication administration record, to ensure all drugs are accounted for and for the purpose of an audit trail. Devise a risk assessment for the named service user on agreed action if the service user continually refuses their medication. YA16 YA17 YA17 6. 7. YA18 YA20 7. YA20 Portland House Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Care Home DS0000002240.V307604.R01.S.doc Version 5.2 Page 27 - 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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