Inspection on 25/09/06 for Portway (200)

This inspection was carried out on 25th September 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 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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Portway (200) 20/09/07

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 25th September 2006 10:10 Portway (200) DS0000022846.V313887.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.V313887.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.V313887.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 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 *** Post Vacant *** Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Portway (200) DS0000022846.V313887.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th October 2005 Brief Description of the Service: Portway is a care home for up to six people with learning disabilities and challenging behaviour. The service users have been living together for over 10 years. The home is registered with the Commissions for Social Care Inspection and inspected accordingly. 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. The range of fees paid at the home is between £1,113.64 and £1,633.71. Portway (200) DS0000022846.V313887.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day lasting some six and a half hours. The aim was to inspect all the key standards and also to monitor compliance with requirements of the previous inspection. The inspector was assisted by the acting manager. She also spoke to residents and one member of staff. The inspector sampled 3 residents files, viewed their medication administration arrangements, cash arrangements, and their keyworkers files. In addition the inspector viewed key documentation and paperwork. She toured the premises including the front and rear gardens, but not all the bedrooms. The inspector would like to take this opportunity to thank the residents and staff at the home for their co-operation and assistance with the inspection. What the service does well: All the residents have been at the home for ten years and some of the staff have worked there for a number of years. This has promoted consistency and stability. The needs of residents are well understood. Most of the administration systems for the proper running of a residential home are in place. The physical environment of the home is good and there is a pleasant summerhouse in the garden which provides a quiet alternative space. Residents are encouraged to be as independent as possible and are encouraged to use the communal spaces in the home, as well as their rooms. Staff are creative in providing opportunities for residents to get out of the house. One resident spoken to indicated he felt he was well looked after at the home. Portway (200) DS0000022846.V313887.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. Portway (200) DS0000022846.V313887.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 Portway (200) DS0000022846.V313887.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): 2. Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to the service. The needs of prospective residents would be assessed, but the home needs to update assessment information appropriately. EVIDENCE: The acting manager advised that all the residents have assessment information on file. The acting manager gave the inspector a good description of the needs of each resident. The inspector sampled evidence and noted that the assessment information was generally quite old. The residents have been at the home for some years. The inspector felt that since the residents have been in placement their needs are better understood than previously. The acting manager stated that four of the residents are regarded as having autistic spectrum disorder although they do not have that formal diagnosis. The inspector believes that the home should undertake reassessment of the residents, if necessary including referrals to specialists. The assessment information can then be formally updated and would reflect the residents needs as they are now. Portway (200) DS0000022846.V313887.R01.S.doc Version 5.2 Page 9 A requirement has been made for this, but a realistic timescale has been given as it is understood that meeting it will take time. The inspector felt, and this impression was confirmed throughout the day, that the individual needs of the residents are not compatible. All the residents have complex needs with learning disability, mental health issues and challenging behaviour. The noise level in the home was consistently high on the day of the inspection. The inspector felt this would be difficult for staff to manage, and stressful for quieter residents, impacting on their behaviour. Some residents spend quite a lot of time in their rooms, which is understandable but does not encourage positive interaction. Should a resident move out for any reason East Living should consider reducing the number of people living at the home to five. This would give the residents more space and assist staff to better meet their needs. Portway (200) DS0000022846.V313887.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 in this outcome area is adequate. The judgement has been made using available evidence including a visit to the service. Residents have plans, take decisions and there is risk assessment. EVIDENCE: The acting manager advised that all residents have a Personal Lifestyle Plan (a service user plan) which is called contains support guidelines. She stated that these are reviewed six monthly by the service and are also reviewed annually by social workers, who sometimes send the minutes through, and sometimes dont. The inspector sampled service user plans on residents files. There was evidence on file of residents having their plans reviewed although not as frequently as every six months. The terminology was rather confusing and the inspector suggests the service use one term consistently for the plan and one term and format for the review. Portway (200) DS0000022846.V313887.R01.S.doc Version 5.2 Page 11 The acting manager stated that all the residents are able to make their needs known and to indicate yes or no. She said that one of the residents can use Makaton but that during her time at Portway Makaton had not been used with the resident. She said there was evidence that it had been used previously and that staff had been trained to use it. The deputy manager further stated that the reviewing of communication needs of all residents is detailed in the home’s business plan. In conversation with the resident he confirmed that he does have a number of Makaton signs. He indicated that he would like to use them. The inspector strongly recommends that the use of signing is facilitated for this resident as a priority. A plan should be made straightaway for his keyworker to learn or refresh his knowledge and develop his skills. The resident and keyworker might be able to attend the lessons together, so that the resident can refresh his own knowledge. The home has a paid sessional worker who has on occasion acted as advocate for residents. The inspector viewed notes of house meetings which are monthly and evidenced residents taking decisions. The inspector sampled evidence on residents files of risk assessment. The acting manager stated that these had been reviewed but unfortunately this had not been noted. The acting manager said that no individual risk assessments had been undertaken for residents recent holidays. Portway (200) DS0000022846.V313887.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. Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. Staff at the home work hard to provide the best lifestyle they can for the residents. EVIDENCE: The residents at the home undertake some educational and recreational activities, inside and outside of the home. One attends art and literacy classes. They all use public transport and have a community presence. Residents are known in local shops and are on friendly terms with their neighbours. The inspector viewed the weekly activity sheet and three daily logs for residents. The logs are completed thrice a day and evidenced individuals getting involved in household tasks. The inspector felt that residents could do more outside of the home and this would ease pressure within the home. The acting manager explained that she is working towards this but is dependent on staffing levels. She said these were cut due to budget constraints, but have been partially restored. The Portway (200) DS0000022846.V313887.R01.S.doc Version 5.2 Page 13 inspector noted that staff are creative in providing opportunities for residents to get out of the house, escorting them on errands to local shops. The acting manager described the relationships and contact that residents have with their families. The inspector was satisfied that the home supports and promotes these relationships. The acting manager described the different support needs of the residents and how staff are able to meet these. Residents are encouraged to be as independent as possible. As previously mentioned residents get involved in household chores. The inspector observed staff interacting positively with residents and treating them with respect. The residents set a menu plan. This is however flexible and residents can choose to opt out of any meal they dont fancy and have something else. A takeaway dinner is purchased fortnightly. Not everyone sits down together and indeed the kitchen table only seats four. Some residents prefer to take their meals alone. There is another table in the lounge where residents eat. The inspector viewed the pictoral menu board which is hung in the kitchen. Lunch is an ad hoc affair with residents deciding individually what they want. Portway (200) DS0000022846.V313887.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 in this outcome area is adequate. The judgement has been made using available evidence including a visit to the service. Personal support is well provided and needs are met, administration of medication was not satisfactory. EVIDENCE: As previously mentioned the inspector viewed service user plans on file. They were called Personal Lifestyle Plan and contained guidelines for working with residents. The acting manager was able to describe the varying needs of residents in detail and stated that staff have a good grasp of them. The staff group at the home has been fairly stable, but should a new staff work with the residents they would be given a basic induction pack of information and also be advised by other staff. The Personal Lifestyle Plan would be made available to them but the acting manager admitted there might not be time for them to read it all before working with the resident. The inspector was satisfied that residents have their personal care provided in a way they prefer and require. The acting manager was able to describe the health care needs of each resident. Three of the residents are under the care of Psychiatrists, one has been referred for psychology. One resident is diabetic and attends at his G.P. Portway (200) DS0000022846.V313887.R01.S.doc Version 5.2 Page 15 surgery for blood sugar monitoring All residents see a dentist and optician regularly. All have local G.Ps. One resident is having some locomotor symptoms and will be seeing a physiotherapist and community nurse for learning disabilities. The inspector suggested to the acting manager that she have a discussion with the community nurse for learning disabilities about whether other residents might benefit from her input, for example with behavioural issues. Referrals could then be arranged. The acting manager stated that staff receive medication administration training, with an examination at the conclusion of the course. Thenceforward they are observed on a regular basis by the trainer. This has lapsed recently as the trainer has not been contactable. Two of the staff have only partially completed their training and therefore cannot administer medication. There is a duty responsible person on each shift who is responsible for medication administration and all recording. The acting manager said that she tries to audit the administration records once a week. However she had just returned from two weeks leave and does not have a deputy. The inspector viewed the arrangements for the administration of medication. Each resident has a section in the medication file with a list of their medications and their photograph. In the case of one resident the photograph was missing. There were gaps on Medication Administration Records Sheets (MARS) for all the three residents the inspector sampled. The acting manager stated that the residents would have been given their medication but the staff member had failed to put her initials on the sheet. The medications are dispensed from the pharmacist in weekly dosette boxes, and each new delivery of medication must be recorded. The manager attempted to balance three medications, to ensure that the record and the stock of medication agreed. She was not able to do this in one case because a delivery of medication had not been recorded. The inspector found a supply of one medication which was surplus and should have been returned to the pharmacy. One resident had apparently not had prescribed cream applied for a period of three weeks. It was then resumed. The acting manager attempted to locate the previous MARS sheet to see whether the resident had been using the Portway (200) DS0000022846.V313887.R01.S.doc Version 5.2 Page 16 cream previously. She could not locate the sheet and stated that staff tend to throw them into the cabinet in a jumble rather than filing them properly. Without evidence to the contrary it would seem that staff allowed the resident to run out of cream and did not have the prescription renewed for three weeks, during which time his skin condition went untreated. Portway (200) DS0000022846.V313887.R01.S.doc Version 5.2 Page 17 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 in this outcome area is adequate. The judgement has been made using available evidence including a visit to the service. Residents are listened to and their views considered, they are protected from abuse and neglect. Some procedures need to be tightened up. EVIDENCE: The inspector viewed the organisational complaints policy, also a lealflet which explains the complaints process. The acting manager stated that a complaints monitoring form is submitted to head office three monthly. A complaint had been received in May of this year. It had been resolved appropriately and the record of this had been signed and dated. The inspector viewed the organisational adult protection policy. The acting manager stated that she had requested the local authority policy from Newham but they had sent her a leaflet. The inspector discussed with the acting manager her understanding of the multi-agency process and was satisfied that she understood it. The inspector suggests that the manager try again to obtain a copy or summary of, Newhams adult protection policy. The inspector viewed the arrangements for residents finances. The residents have two accounts, a current account and a savings book. The current account cards, cheque books and bank statements are kept in a safe that only th manager has access to. The pass books, to which money is transferred from the current accounts, are kept in a locked tin inside a second safe which Portway (200) DS0000022846.V313887.R01.S.doc Version 5.2 Page 18 all staff can access. No pin numbers are kept so staff must go with residents to the bank to withdraw or transfer money. Residents cash is kept in purses in the safe. The inspector viewed three residents records of cash expenditure, and counted their cash balances. Two balanced but a third was 50p over. This is not in itself a grave concern but as the resident had not spent anything for over a week, it does indicate that the practice of counting the cash at each staff handover is not being followed. Portway (200) DS0000022846.V313887.R01.S.doc Version 5.2 Page 19 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 in this outcome area is good. The judgement has been made using available evidence3 including a visit to the service. The environment is homely, comfortable and clean. EVIDENCE: The inspector toured the premises including the front and rear garden and the summerhouse. She was pleased to note that the home has responded to previous requirements concerning the environment of the home. The sitting room furniture has been rearranged so that everyone has a comfortable view of the television. A resident has had a washable flooring laid in his room ensuring that no unpleasant odours build up there. The window boxes and hanging basket in the front of the home are finished and need to be either replanted or removed for the winter. The house is generally in good decorative order, with the exception of a downstairs shower room which has peeling paint and rust. This shower room needs to be decorated. The manager stated that there are plans to redecorate Portway (200) DS0000022846.V313887.R01.S.doc Version 5.2 Page 20 the communal areas and also some exterior work. The office needs redecorating and hopefully this will also be done. The inspector was pleased to note that the home now has a lockable clinical waste bin, this having been a requirement of the previous inspection. The home has a washing machine with a sluice facility, and a programme for high temperature washes. The laundry area has an impermeable floor. It can be accessed without the need to walk through the kitchen. There are wash hand basins in the laundry and kitchen areas. Portway (200) DS0000022846.V313887.R01.S.doc Version 5.2 Page 21 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): 32,34 and 35. Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to the service. Recruitment is sound and staff are qualified and competent. More input is needed into training and supervision. EVIDENCE: The acting manager stated that previous experience is not essential for job applicants. She said that personal attributes and a person centred approach are more important. Five out of the nine care staff have NVQ level 2 and one has NVQ level 3, Promoting Independence. Some staff have been at the home a number of years giving stability and consistency to the staff group. The night staffing for the home is one waking night staff. The inspector discussed this with a staff member and asked is she had ever had a situation where two residents were awake and needing her at the same time during the night. She said that this had happened and she had had to settle one resident in her room and bring another downstairs to sit with her. In addition night staff are expected to undertaken household chores like ironing, on their shift. Portway (200) DS0000022846.V313887.R01.S.doc Version 5.2 Page 22 The inspector felt that one waking night staff was scarcely sufficient for the needs of the six residents. She felt that the situation should be monitored over the next few months to see how often and how many people do actually need staff attention during the night. The acting manager stated that the organisational policy for staff interviews is to have a gender and culture balance on panels. The panel asks questions linked to competencies. They have marking forms. References are taken up as are Criminal Records Bureau checks. The inspector was not able to view documentary evidence of the above as the information is kept at the human resources department of the organisation. The inspector viewed the East Thames learning calendar. The acting manager said that the home has a training budget to fund external training such as team building days. The inspector sampled staff files to evidence training and development. There was evidence of general training undertaken and there had been in-house fire training in May this year which a number of staff had attended. However some other core training topics for example food hygiene and manual handling had not been renewed. The acting manager stated that the standard set by the organisation for supervision is monthly and she has been supervising staff every three months. The National Minimum Standards require staff to be supervised six times per year. Staff files evidenced supervision occurring less frequently than required. However three staff members had had personal development meetings, although one recording had not been signed or dated. Portway (200) DS0000022846.V313887.R01.S.doc Version 5.2 Page 23 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 in this outcome area is adequate. The judgement has been made using available evidence including a visit to the service. The acting manager and staff at the home endeavour to run it well. Residents views are taken into account and their safety and welfare is promoted. EVIDENCE: The deputy manager has been seconded to acting manager for over two years. She does not have the support of a deputy and finds she has to prioritise her tasks, being unable to complete everything she needs to do. The inspector felt that the shortcomings in the administration of medication and the supervision of staff bore this out. The situation with regard to the management of the home needs to be resolved urgently and a requirement was made at the last inspection regarding this. It has been restated. The acting manager stated that from time relatives meetings are held. The relatives have formed themselves into a group with a spokesperson. Portway (200) DS0000022846.V313887.R01.S.doc Version 5.2 Page 24 Questionnaires are circulated to residents and relatives and a sessional worker assisted some of the residents with completion. Once completed the forms are returned to head office, so unfortunately could not be viewed by the inspector. East Living does hold residents forums and one of the residents has attended. Staff felt that the other residents would not have coped well with the demands of the day. The resident who attended the forums has also undertaken recruitment training and the inspector saw the certificate he had been awarded. The inspector viewed the fridge and freezer temperatures which had been appropriately recorded. Residents all have hand basins in their rooms and the inspector viewed the recording of water temperatures and noted that all taps are done every week. The manager stated that Portable Appliance Testing (PAT) had been undertaken recently and the appliances all have stickers but no invoice has been received yet. She will also be arranging a date and getting a quotation for PAT testing of residents’ appliances. The manager stated that residents will be required to pay for the testing of their personal appliances, i.e. televisions CD players etc. The manager must ensure that this piece of policy on behalf of the organisation does not interfere with the safe running of the home. It must not prevent PAT testing of all appliances in the home. The inspector noted that the home electrics were tested in April 04 and that a new boiler certificate was issued in August 2006. As previously stated the waking night staff works alone. The manager stated that the home has a risk assessment for lone working . The manager stated that a health and safety inspection had been carried out and the home has been asked to produce a Fire Wallet. This would contain a fire risk assessment, evacuation procedure, list of fire protection and fire fighting equipment. A requirement has been made to ensure compliance with this health and safety request. The manager stated that the fire extinguishers were all checked and one may need replacement. If this is necessary it must be done. Portway (200) DS0000022846.V313887.R01.S.doc Version 5.2 Page 25 The manager stated that the fire alarm was serviced on 28/4/06and the emergency lighting on 28/4/06. There was documentary evidence of this. The home operates a rota for checking that the alarms points are working. The had fire drills on 26/9/05, 15/10/05 and 4/4/06. The inspector advised the manager to have drills when she is not present, so that staff have some experience of managing a fire drill. The manager stated that the Control of Substances Hazardous to Health (COSH) arrangement were not fully in order. She stated that the home limits itself to a range of products, but that the product information for them was not available. The home is working with an outside consultancy called JANGRO which will supply the product information. Portway (200) DS0000022846.V313887.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 X 2 2 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 3 23 2 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 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 1 x 2 x 3 x x 2 x Portway (200) DS0000022846.V313887.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. Standard YA2 Regulation 14 Requirement The registered person must ensure that home undertakes reassessment of the residents, if necessary including referrals to specialists. The assessment information can then be formally updated and would reflect the residents needs as they are now. The registered person must ensure that risk assessments are undertaken whenever necessary. The registered person must ensure that risk assessments are reviewed regularly and that this can be evidenced. The registered person must ensure the following with regard to the administration of medication: All residents have their photograph in their medication folder. There are no gaps in the recording of administration of Portway (200) DS0000022846.V313887.R01.S.doc Version 5.2 Page 28 Timescale for action 01/04/07 2. 3. YA9 YA9 14 14 01/11/06 01/01/07 4. YA20 13 01/12/06 medication. All medication received into the home is recorded. Surplus medications are returned to the pharmacy and signed for by the pharmacist. Residents are not allowed to run out of prescribed medications including creams. All recording pertaining to medications is correctly filed and accessible. The registered person must ensure that residents cash balances are checked at each staff handover. The registered provider must ensure that the downstairs shower room is redecorated. The registered person must monitor the night staffing needs by recording the incidences of residents needing staff attention during the night. This record must be available for inspection. The registered person must ensure that staff renew their core training annually. The registered person(s)must ensure that staff (including management) receive appropriate support and supervision and that the minutes of at least six meetings a year are available for inspection (previous timescale of 30/11/05 not met). The registered person(s) must ensure that personal development plans are signed and dated by both parties. The registered person(s) must ensure that an appropriate person apply to the Commission DS0000022846.V313887.R01.S.doc 5. YA23 12 01/11/06 6. 7. YA24 YA32 23 18 01/03/07 01/12/06 8. 9. YA35 YA36 18 18 01/01/07 01/12/07 10. YA36 18 01/12/07 11. YA37 8 01/01/07 Portway (200) Version 5.2 Page 29 12. YA42 23 13. YA42 23 14. YA42 23 15. YA42 23 for Social Care Inspection to be registered as manager of the home (previous timesdcale of 31/01/06 not met). The registered person must ensure that the requirement for residents to pay for the PAT testing of their personal items does not interfere with the safe running of the home. It must not prevent PAT testing of all appliances in the home. The registered person must ensure that the home produces a Fire Wallet in response to the request of the health and safety inspection which was carried out. The registered person must ensure that all the fire extinguishers on the premises are in working order. The registered person must ensure that the COSHH arrangements are satisfactory with product information for all the products kept in the home. 01/12/06 01/03/07 01/12/06 01/01/07 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. Refer to Standard YA6 Good Practice Recommendations The acting manager should ensure that the service uses one term consistently for the service user plan and one term and format consistently for the reviews. The inspector strongly recommends that the use of signing is facilitated for this resident as a priority. A plan should be made straightaway for his keyworker to learn and develop the skill. The resident and keyworker might be able to attend the lessons together, so that the resident can refresh his own knowledge. The acting manager should try to provide more activity outside of the home for residents. DS0000022846.V313887.R01.S.doc Version 5.2 Page 30 YA7 3. YA12 Portway (200) 4. YA19 5. 6. YA22 YA30 The acting manager should have a discussion with the community nurse for learning disabilities about whether other residents might benefit from her input, for example with behavioural issues. Referrals could then be arranged. The inspector suggests that the manager try again to obtain a copy or summary of, Newhams adult protection policy. The window boxes and hanging basket in the front of the home are finished and should be either replanted or removed for the winter. Portway (200) DS0000022846.V313887.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection East London Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Portway (200) DS0000022846.V313887.R01.S.doc Version 5.2 Page 32 - 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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