Inspection on 20/09/07 for Portway (200)

This inspection was carried out on 20th September 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Portway (200) 25/09/06

Portway (200) 11/10/05

Portway (200) 27/07/05

Portway (200) 06/10/04

Portway (200) 14/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Portway (200) 200 Portway Stratford London E15 3QW Lead Inspector Anne Chamberlain Unannounced Inspection 20th September 2007 10:15 Portway (200) DS0000022846.V348476.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 Portway (200) DS0000022846.V348476.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. Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Portway (200) Address 200 Portway Stratford London E15 3QW 020 8552 9164 NO FAX gary.reeman@east-living.co.uk 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) East Living Limited vacant post Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th September 2006 Brief Description of the Service: Portway is a care home for up to six people with learning disabilities and challenging behaviour. The residents have been living together for over 10 years. The building is a large house situated opposite West Ham Park, close to local amenities and Stratford shopping centre. There is a rear garden with a summer house, shed and green house. The Registered provider of the service is East Living, part of the East Thames group. Fees paid at the home are around £1,658.00 per week. Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The is the third inspection which the inspector has undertaken at this service. Prior to the site visit an Annual Quality Assurance Assessment was received and this provided useful information about the service. The aim of the unannounced visit was to inspect all the key standards and measure compliance with the requirements of the previous inspection. The inspector met with residents and spoke privately with a relative. She case-tracked three residents viewing their files, personal monies and administration of medication. The inspector also viewed the staff personnel files for the keyworkers of the residents, and key policies, procedures, records and documentation. She made a tour of the premises. The household is proposing to move to what is considered to be accommodation better designed and equipped to meet the individual needs of the residents. The new home is quite local and the inspector viewed it. The manager was assisted in her inspection by the manager and staff. She would like to take this opportunity to thank them and the residents for their assistance and co-operation with the inspection. The inspector came to see if people were being well cared for at the service. She will write a report about what she found. What the service does well: The systems in the home which underpin and record the care given are stronger and are being used more effectively. Residents needs are well understood and staff are supervised regularly. Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 6 Relatives are welcomed and the home works with them. One relative interviewed said she had no complaints about the care of her daughter. The home supports a range of activities for residents and also involves them in the running of the household. The environment at the home is quite noisy and busy, but the condition of décor and cleanliness is good. T The inspector found that residents were just about to go on holiday, but they do activities at home too. What has improved since the last inspection? The previous inspection carried twelve requirements and a number of these have now been met. The new manager has worked on several areas including reassessment of residents, reviewing of their care plans and risk assessments, and the supervision of staff. The systems and records of the home appear to be in Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 7 much better shape than previously and the manager was able to locate documentation quickly for the inspector. The inspector found that the office was better organised and the manager could find the records she needed to look at. What they could do better: The inspection resulted in nine legal requirements and four good practice recommendations. Unfortunately some of the requirements are restated. Is acknowledged however, that the manager has not been in post for many months. Also that the service had previously undergone a period of unstable management. The service user guide and complaints information both need to be amended and updated. Residents are doing more and this needs to be reinforced and underpinned by structured timetabling. A resident is able to use Makaton and should be encouraged and supported to do this by his keyworker using Makaton with him. Medication practice needs to be improved and so does staff training. As previously mentioned the household is proposing to move to new accommodation and the manager and senior management believe this will be better for the residents. The inspector is not entirely convinced at this stage, and believes the results of the reassessment should not be pre-empted. The inspector found that some staff needed to do more training Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 8 and some documents needed to be updated. 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. Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 9 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 Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Residents experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. A thorough reassessment of the needs of the current residents is being undertaken. EVIDENCE: The inspector viewed the service user guide on the files of residents. It is out of date, giving the name of the previous manager and incorrect information about the care home fees. The name of the previous lead inspector is given and also the previous address of the Commission for Social Care Inspection (CSCI) (see requirements). The previous inspection required the home to reassess the residents, to establish whether their individual needs can be met in the group setting. This process is underway and the inspector viewed the form which is being used. Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 11 The first reassessment was undertaken on 28th August and there are dates booked for all the residents, the last one being on 4th October. The inspector is satisfied that the needs of the residents are being reassessed thoroughly. Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Residents experience adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. There is work in progress in this outcome area. Improvements have been made but there is scope for more individual choice and decision making. EVIDENCE: The inspector viewed the service user plans on the files of the three residents she case-tracked. These were generally of a good standard. However one residents plan needed amendment because her family situation has changed (see requirements). In addition residents had personal lifestyle plans and in some cases behaviour support guidelines. The inspector felt that the needs of the residents were well understood. The inspector and the manager agreed that some of the challenging behaviours of residents were institutional in nature and indicated unmet need. The manager hopes that the proposed move to more suitable accommodation will provide a calmer atmosphere for residents. Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 13 The inspector noted that one resident had had their care plan reviewed in July this year. Another resident has a review booked for the near future. The manager stated that the family and social worker will be invited to the reviews. The inspector felt that care plans are being appropriately reviewed now. The manager must ensure that if the review indicates a change the service user plan is updated to reflect it. Also to work towards any goals which are set. The manager stated that residents are encouraged to make decisions regarding their lives. Reviews include goal setting with residents who might decide to drop activities or start new ones. The home is developing timetables of activities. There should be individualised timetables for residents in a user friendly format, and a timetable for the whole household. These can be laminated and posted in all appropriate places to help residents and staff to plan and organise their days and weeks (see requirements). One resident in the home can sign in Makaton but has no-one to sign with. The manager stated that on first working with this person he did not feel it necessary to train his keyworker in Makaton as the resident could make his needs known. However the resident has since then had a hearing problem and the manager now agrees that the Makaton should be encouraged and the keyworker should undertake Makaton training (see requirements). In this way the resident will be better equipped to communicate his views and decisions. The home undertakes risk assessments and the inspector noted that residents files contained individualised risk assessments. There was evidence that these had been updated. The home also keeps general risk assessments in the health and safety file. Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Residents experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Again work is still in progress in this outcome area. However residents are getting out more and having more opportunities for personal development. EVIDENCE: The inspector went through the activities of residents with the manager. These included attendance at day centres, visits to family homes, shopping, walks in the park, aromatherapy Bubble club etc. Residents daily log books provided documentary evidence, The manager stated that people are doing more because activities are detailed on their individual plans. He said that he has encouraged staff to take residents out of the house more and this has contributed to a lessening of tension and noisiness in the house. Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 15 All the residents had holidays planned for the week following the inspection. They were going in two groups, one of men and one of ladies to two different locations. The manager stated that all the residents take part in some domestic activity towards the running of the house. They also assist with their own laundry and someone always comes along to help with the food shopping once a week. The inspector was told that lunch is a relaxed meal with people choosing what they fancy on the day and eating at different times. Dinner is also not taken together. The home does not have a table large enough at present. However if the household moves to the other location which is being considered, they will have a table large enough to accommodate everyone at once. This will be much more suitable for special occasions like Christmas. The inspector viewed the pictoral menu board which is in the kitchen and also the contents of the refrigerator. The refrigerator contained among other things a good quantity of fresh vegetables. The inspector was satisfied that residents choose foods that they like to eat, and that they are provided with a healthy nutritious diet. Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Residents experience adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Personal and health care support is good but medication practice needs some strengthening EVIDENCE: Residents had on their files health action plans, which were viewed by the inspector. Unfortunately the plans had not been dated. The inspector suggests the manager dates the plans even if this has to be a best guess. The manager stated that residents have differing levels of independence and need different levels of support with personal care. One resident is diabetic and the manager said that staff are going to be taught how to assist the resident to monitor his blood sugar at home, instead of going each week to the clinic. Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 17 A resident is being referred to s specialist consultant for assessment of some physical symptoms, another will be seeing a consultant at his review in a few days. Another resident has a referral made to occupational therapy for help with shaving more independently. The inspector had the impression that residents health is well monitored and they are being referred to specialists where necessary. There was also evidence that residents attend at the octicians and dentist. The inspector viewed the arrangements for the administration of medication. A folder is kept with the medication administration record (MAR) sheets and the inspector viewed them for the three residents she was case-tracking. One resident had two bottles of prn medication, both dated 2006. The manager must ensure that the older preparation is disposed of (see requirements). Another resident had a medication dated 2005 which he has not taken recently. This must be disposed of (see requirements). The home holds a controlled drug but does not have a controlled drugs register. The inspector explained to the manager that this was necessary and pointed out to him in the organisations medication policy where this matter is discussed (see requirements). The home disposes of medications by returning them to the pharmacist. This is good practice. However the home must obtain a signature from the pharmacist or his representative as a receipt of the medication (see requirements). The manager stated that he has not yet had medication training himself. This must be addressed as quickly as possible (see requirements). The inspector discussed with the manager the new regulations with regard to smoking. She found him well informed and that suitable arrangements had been made in the home for those who smoke. Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Residents experience adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The structures are in place to protect adults but some updating is needed. EVIDENCE: The home has an organisational complaints policy and the manager stated that complaints are reported to head office. One complaint has been received which is being dealt with under adult protection, discussed later in this report. The complaints procedure was not visible in the home and the manager agreed to put a copy on the residents notice board (see recommendations). The inspector viewed the complaints information in the files of residents. It needs to be updated as it names the previous manager, and the previous inspector. The manager advised it is best not to name inspectors. It is not possible to contact inspectors directly as they work from home. Also the procedure has no timescales (see requirements). The inspector viewed the organisational policy for the safeguarding of adults. It contained a useful procedural flow chart which showed how the referral is likely to be handled by social services. Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 19 The manager was not able to produce the local social services adult protection policy. The home should have a copy of this as it is to be followed in conjunction with their own policy (see requirements). As mentioned above an allegation has been made against a carer and this is currently being investigated. In the meantime the carer has been suspended from duty at the home. The complaint was made in May this year and the inspector feels the matter is rather overdue for resolution (see recommendations). The manager was concerned that staff training on adult protection is not up to date and this is dealt with later in the report. The inspector viewed the accounts for two residents and counted their personal monies to ensure there were no discrepancies. Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Residents experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The environment of the home is good and has the benefit of a large garden with summerhouse and greenhouse. A recommendation has been made towards noise reduction. EVIDENCE: The inspector made a tour of the home and garden. The environment of the home is generally good. The décor is quite fresh and sound and the home was clean and well presented. The inspector was pleased to note that the garden shed was properly locked and that there were troughs and a hanging basket in the front garden, in bloom. Noise levels in the home seemed better than on previous visits. However a major contribution to the noise level is made by the office door which residents Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 21 who are in and out of the office quite a lot, usually leave to slam on its own. The door slams very loudly. The inspector has visited the home three times and has twice left with a migraine headache. The inspector recommends that a slow closer is fitted to the office door for the benefit of all who use the home (see recommendations). The does have some foul laundry. The washing machine has a suitably hot programme and the floor in the utility area is impermeable. The resident who handles the foul laundry wears gloves and an apron and anti-bactericidal hand rub is provided. Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 ,35 and 36. Residents experience adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Recruitment is safe and supervision is regular but staff training must be brought up to date. EVIDENCE: There are nine staff and six have NVQ 2 at least. Two are enrolling on the course this year. The inspector felt that there has been some stability in the staff group and their level of competence is reasonable. The manager is well supported by a newly recruited deputy. The manager and inspector agreed that the staff now need a period of managerial stability and strong leadership. The home has recently had a team building day and this has been beneficial. The manager feels that there are signs of staff taking more responsibility with increased use of the communication book and more communication generally. Regular monthly team meetings are now held. Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 23 The inspector spoke with the deputy manager who explained the process of her recruitment, induction and probation. The inspector believes that recruitment systems are safe and robust, and residents are protected by them. The level of staff training falls below expectations. The manager and inspector agreed that core training comprises of health and safety, including food hygiene and infection control, fire, first aid and safeguarding adults. These topics must be repeated annually unless the training is designed to be renewed less frequently and the certificate confirms this. Staff must have up to date medication training and up to date assessment to administer medication. It is important that the manager receive his medication training urgently so that he is able to monitor the administration of medication personally. The staff group have attended various training courses at various times and some are more up to date on some topics than others. The manager and inspector agreed that the task now is to ensure that all staff have the training they need brought up to date. They also agreed that the manager needs to have a matrix for the overall situation and lists of training for individuals. The manager must ensure that staff training needs are properly assessed and documented and plans made to address these needs. Staff must not administer medication unless they have been assessed as fit to do so not more than twelve months ago (see requirements). The inspector viewed the documentary evidence of supervision on the personnel files of workers. The frequency of supervision has improved. The inspector noted however that supervision notes had not always been signed (see recommendations). The inspector noted evidence of staff appraisal. Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): Residents experience good quality in this outcome area. 37,39 and 42. This judgement has been made using available evidence including a visit to this service. The manager is competent and is running the home well. Quality assurance is monitored in a number of ways and the safety and welfare of the residents is promoted and protected. EVIDENCE: The manager is new and has been in post for a few months. He has a substantial amount of experience in various services for individuals with learning disability. He told the inspector he is enrolling on the registered Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 25 managers award and has submitted to CSCI his application to be the registered manager of the service. The inspector formed the view that the manager has the experience and competence to run the service well. He perceives the potential of the residents for further personal development and is committed to providing the opportunities for them to achieve this. The home has various methods for obtaining quality assurance feedback. Person in Control visits are undertaken. Service user forums are held but are not suitable for all the residents. There is a monthly residents meeting and the inspector viewed the recent minutes. These indicated a good agenda and interaction. The inspector was told that all the residents are going to be referred for advocacy. She felt that this would help them express their views better over a number of issues including the running of the home, and moving to a new home. The inspector viewed the arrangements for the Control of Substances Hazardous to Health (COSHH). The home mainly uses products from one source and these are locked away properly. Product information is kept for these products. There was one product stored which had been provided by the supplier as a substitute, and for which no information was available. The inspector was satisfied that this was an isolated occurrence. The folder of product information sheets was in need of revising and tidying and the manager agreed that this would be done. The inspector viewed the arrangements for fire protection. There is a policy and a risk assessment, and drills are held every three months. The time of day is varied, the last one being held at 11.30a.m. The time for evacuation is recorded and on that occasion was seven minutes. An outside contractor inspected the fire extinguishers in April 2007 and the control panel in June 2007, the fire alarm on 19th September 2007. The manager stated that the fire alarm is tested once a week. The home had the portable appliances tested on 7th August 2007. The organisation insists on charging residents for the testing of their appliances. The inspector was assured that this is a very small sum of money and the practice does not prevent testing of all appliances in the home. Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 26 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 2 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 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 x 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 3 x Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 27 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. 2. Standard YA1 Regulation 5 15 Requirement The service user guide must be updated and the inaccuracies corrected. The care plan of one resident needs to be amended to take into account the change in her family situation. Individual timetables and a timetable for the group of residents must be developed. Timescale for action 01/11/07 01/10/07 YA6 3. YA7 15 01/11/07 4. 5. YA7 15 13 YA20 These must be posted in appropriate places to help residents and staff to plan and organise the week. The keyworker of the resident 01/01/08 who is able to use Makaton must be trained to use Makaton. 19/10/07 The manager must ensure that the older of the two preparations dispensed for a resident in 2006 is disposed of. The medication dispensed in 2005 which the resident has not taken recently must be disposed of. The registered person must ensure that receipt, Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 28 administraton and disposal of controlled drugs are recorded separately on a controlled drugs register (previous timescale of 01/05/07 not met) . The registered person must ensure that surplus medications are returned to the pharmacy and signed for by the pharmacist (or his representative) (previous timescales of 01/05/07 and 01/12/06 not met). The manager must have medication training. The complaints information needs to be updated. 6. 7. YA20 YA22 13 13 01/01/08 01/11/07 8. 9. YA23 YA35 References to the previous manager, and lead inspector must be deleted, and the procedure must have timescales. 13(6) The manager must seek to acquire a copy of the local social services adult protection policy. 18(1)(c)(1) Staff training needs must be properly assessed and documented, and plans made to address these needs. Staff must renew their core training annually (previous timescale of 01/06/07 not met). Staff must not administer medication unless they have been assessed as fit to do so within the last twelve months (previous timescale of 01/06/07 not met). 01/12/07 01/11/07 Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 29 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. Refer to Standard YA22 YA23 YA24 YA36 Good Practice Recommendations The manager should put a copy of the complaints information on the residents notice board. The manager should seek resolution for the adult protection investigation which dates back to May. A slow closer should be fitted to the office door to prevent it from slamming noisily. Staff supervision notes should be signed by both parties. Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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. Extracts may not be used or reproduced without the express permission of CSCI Portway (200) DS0000022846.V348476.R01.S.doc Version 5.2 Page 31 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!