Care Home: Portcullis House

Similar services:

• Fairfields Country Rest Home
• Poldhu
• Queensmount
• Trevaylor Manor
• Didsbury Court Rest Home
• Belma
• Hunters Care Centre
• Manor Lodge

What the care home does well Anyone wishing to move into the home has their needs fully assessed to ensure that Portcullis House is able to meet their needs and expectations. People receive adequate information about the home and they and their representatives are able to visit before making any decisions. Everyone spoken with felt that their privacy was respected and that personal care was carried out in a sensitive manner. The inspectors observed that interaction between people living and working at the home was kind and respectful. There is a complaints procedure in the home and people spoken to stated that they would be comfortable to raise any concerns with a member of staff. There are clear lines of accountability and responsibility. There is always a senior member of staff on duty to offer support and guidance to less experienced members of the team.Recruitment practices are robust and minimise the risks of abuse to people who live at the home. What has improved since the last inspection? At the last inspection some people stated that they had limited choices about their day to day lives. At this inspection there was a relaxed atmosphere in the home with people stating that they were able to make choices about what time they got up, when they went to bed and how they spent their day. A new manager has been employed who is currently in the process of registering with the Commission for Social Care Inspection. Robust quality assurance measures have been put in place and there is a commitment to identifying areas that need developing to ensure ongoing improvements. Staffing levels have been reviewed and additional staff hours have been made available. Staff files seen demonstrated that all new staff receive a structured induction including health and safety training. Records of staff training showed that mandatory staff training is now up to date and training specific to individual roles is booked for the coming months. Two activity workers are now employed and there is a wide range of organised activities, including trips out. People spoken to were happy with the activities organised by the home. Staff have worked hard to improve the quality of care plans. A new computerised system has been put in place and care plans now give clear guidelines to ensure that staff support people in their chosen way. There was evidence that people living at the home are now more involved in the creation and review of care plans. Medication practices have improved and there are now protocols in place for the use of `as required` medication and any medication that is self administered or given covertly. There is a refurbishment programme in place. The laundry is being redeveloped to include the provision of separate hand washing facilities to ensure good infection control practices. What the care home could do better: Care plans seen contained life histories, these were variable in quality and the manager stated that this is an area that they hope to develop in the future.One assessment in respect of tissue viability had been incorrectly completed which could potentially mean that the person did not receive the appropriate preventative care required. A member of staff gave evidence that additional training in the Protection Of Vulnerable Adults may be beneficial to ensure that everyone is clear of the procedure to follow if an allegation of abuse is made. All accidents in the home are recorded but some records seen did not give details of the treatment given at the time of the accident. This was a requirement of the last inspection and has not been fully complied with. Bathrooms and toilets in the home are tired looking and in need of redecoration. It is strongly recommended that all personal monies held, and the amenity fund, are regularly audited by someone independent of the home. CARE HOMES FOR OLDER PEOPLE Portcullis House The Embankment Langport Somerset TA10 9RZ Lead Inspector Jane Poole Unannounced Inspection 28th May 2008 10:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Portcullis House Address The Embankment Langport Somerset TA10 9RZ 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) 01458 250800 01458 253772 Somerset Care Limited Mrs Christine Carol Dowdell Care Home 40 Category(ies) of Dementia - over 65 years of age (40), Old age, registration, with number not falling within any other category (40) of places Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Registered for 40 persons in categories OP and DE (E) One named service user aged under 65 years to be admitted to the home 6th November 2007 Date of last inspection Brief Description of the Service: Portcullis House is a purpose built residential home, located within a residential area of Langport. There is a range of communal areas at the home. A passenger lift, assisted bathrooms and a call system are provided. The home is set in pleasant gardens that are accessible to service users. The home is registered with the Commission for Social Care Inspection to provide care for up to 40 residents over the age of 65 years. Within the home there is a Specialist Residential Care (SRC) unit called Rose Garden that provides additional care and support to residents who have a dementia. The Registered Provider is Somerset Care Limited. Fees at the home range from £390.00 to £490.00 Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are: - excellent, good, adequate and poor. Two inspectors spent the day at Portcullis House, they were able to talk with people living and working at the home, meet with visitors and observe care practices. The inspectors were given unrestricted access to all areas of the home and all records requested were made available. Prior to the inspection the manager completed an Annual Quality Assurance Assessment. (AQAA) This set out the improvements made since the last inspection and the homes plans for the future. The AQAA demonstrated a commitment to improving the quality of care at the home. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: Anyone wishing to move into the home has their needs fully assessed to ensure that Portcullis House is able to meet their needs and expectations. People receive adequate information about the home and they and their representatives are able to visit before making any decisions. Everyone spoken with felt that their privacy was respected and that personal care was carried out in a sensitive manner. The inspectors observed that interaction between people living and working at the home was kind and respectful. There is a complaints procedure in the home and people spoken to stated that they would be comfortable to raise any concerns with a member of staff. There are clear lines of accountability and responsibility. There is always a senior member of staff on duty to offer support and guidance to less experienced members of the team. Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 6 Recruitment practices are robust and minimise the risks of abuse to people who live at the home. What has improved since the last inspection? What they could do better: Care plans seen contained life histories, these were variable in quality and the manager stated that this is an area that they hope to develop in the future. Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 7 One assessment in respect of tissue viability had been incorrectly completed which could potentially mean that the person did not receive the appropriate preventative care required. A member of staff gave evidence that additional training in the Protection Of Vulnerable Adults may be beneficial to ensure that everyone is clear of the procedure to follow if an allegation of abuse is made. All accidents in the home are recorded but some records seen did not give details of the treatment given at the time of the accident. This was a requirement of the last inspection and has not been fully complied with. Bathrooms and toilets in the home are tired looking and in need of redecoration. It is strongly recommended that all personal monies held, and the amenity fund, are regularly audited by someone independent of the home. 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. Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are opportunities for people to visit the home before deciding to take up residency. Everyone wishing to move into Portcullis House has their needs assessed to make sure it offers an appropriate level of care. Intermediate care is not provided. EVIDENCE: Since the last inspection the home has up dated their statement of purpose to reflect changes that have occurred in the home. It also now includes emergency and fire procedures. Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 10 There are opportunities for people to visit the home before deciding to move in, however most people spoken to said that they relied on friends or relatives to view it on their behalf. In addition to full residential care the home offers respite care and one person said that they had decided to make Portcullis their home after a respite stay. The inspectors viewed the personal file of someone who had recently moved to the home. A pre-admission assessment had been carried out by the manager and a copy of a full assessment completed by professionals outside the home had been obtained. The assessments clearly set out the persons’ needs and abilities and identified that the home offered an appropriate level of care. Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements in care plans mean that there are now clearer guidelines to enable staff to assist people with their care. People living at the home have access to healthcare professionals in line with their individual needs. Privacy is respected. EVIDENCE: Since the last inspection all staff have worked extremely hard to improve the quality of the care plans. The system for care planning has been changed to a computerized system, although hard copies are maintained for people who wish to view them in a more traditional format. The inspectors viewed a sample of 5 care plans and found them to be comprehensive and give clear Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 12 guidelines for staff to follow. There was evidence that people living at the home are now more involved in the creation and review of care plans. It was noted that care plans were discussed at a recent residents meeting and some plans of care had been signed by the people who they related to. Records of reviews showed that the person had attended their review and had been involved in discussions about their ongoing care needs. Care plans gave information not just about the needs of a person but also about their likes, dislikes and preferences demonstrating that the home is working towards more person centred care. There is a section in the care plan for a brief life history of the person and these were variable in content. The manager stated on the day, and in the Annual Quality Assurance Assessment (AQAA) completed prior to the inspection, that they are hoping to further expand life histories to give a fuller picture of the individual. Currently no one living at the home has a pressure sore but tissue viability assessments are completed and reviewed regularly. One assessment seen had been incorrectly completed giving an inaccurate score, which could potentially mean that the person did not receive the preventative care required. The inspectors observed that pressure relieving cushions were in place for people assessed as being at high risk. Records of all appointments with healthcare professionals are maintained and people living in the home are regularly weighed. Weight records seen showed that people were generally maintaining a steady weight. One person had lost a considerable amount of weight and advice had been appropriately sought from medical professionals. People spoken to on the day of the inspection stated that their privacy was respected. One person said that staff were “very sensitive with personal care and always ask me private things when I’m in my room.” Throughout the day the inspectors observed that staff interacted with people living at the home in a polite and kind manner. In the specialist unit; Rose Garden, which cares for people who have a dementia, the inspectors noted that staff respected privacy and assisted people in a dignified manner. The inspectors saw that people were able to choose whether to spend time in the company of others or in the privacy of their personal rooms. The home uses a Monitored Dosage System (MDS) for medication. Medication is administered by senior staff who have received training in this area. The Medication Administration Records (MARs) were viewed and found to be well maintained and correctly signed when administered or refused. There are protocols in place for the use of ‘as required’ medication and any medication that is self administered or given covertly. Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to make choices about their day to day lives. To help people keep in touch with friends and relatives, visitors are made welcome in the home. EVIDENCE: There was a relaxed atmosphere in the home. People spoken to stated that they were able to choose when they got up, when they went to bed and how they spent their day. Since the last inspection the home has improved the activities available to people living in Rose Garden and the main part of the home. Two activity workers are now employed to ensure that there is more stimulation available to people. There was an activities programme on display in each part of the home. At this inspection everyone asked was happy with the activities available although some people said that they chose not to join in with any Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 14 organised activities. During the day there was an art session in Rose Garden in the morning and a music session in the afternoon. In the main part of the home a church service was held and a group went out in the afternoon to play skittles. There are books and magazines available throughout the home. Both activities workers are registered to undertake a certificated training course in providing activities. The inspectors saw photos of activities that had been undertaken by people in the home, these included crafts, flower arranging, gardening, cake making, tea parties and trips out. The manager stated that to maintain peoples’ skills and interests they are encouraging all staff to assist people to take part in meaningful occupation as well as organised activities. One person, who lived in Rose Garden, told the inspector that they assisted with washing up and another person said that they liked to lay the tables for meals. During the day the inspectors talked with 4 visitors to the home. All stated that they were able to visit at any time and were always made welcome. The majority of people spoken to were happy with the quality of food, one person described the meals as ‘plain but tasty’ another said the ‘food is always good.’ The main meal each day is at lunch-time with a lighter meal in the evening. There is a dining area in Rose Garden, and two dining rooms in the main part of the house. There are plans for two of the three dining rooms to be refurbished in the coming months. The inspectors viewed lunch being served in two areas. There was a choice of two main courses and a selection of puddings for people to choose from. Each table had a serving dish of vegetables so that people could help themselves. Assistance was offered to people who required help. Cold drinks were served with the meal. Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment practices minimise the risk of abuse to people living at the home. Visitors and people living at the home feel able to approach staff if they are unhappy about any aspect of care. EVIDENCE: The home has policies and procedures in respect of making a complaint, recognising and reporting abuse and whistle blowing. There is an up to date copy of Somerset’s Safeguarding Vulnerable Adults policy in the home, which gives clear directions to follow if an allegation is made. Many staff have received training in the protection of vulnerable adults and the area manager stated that further training is planned. One member of staff spoken with was unclear about the procedure to follow if anyone raised concerns with them. The complaints procedure is displayed in the home and available in the service user guide. People living at the home stated that they would be comfortable to raise any concerns with a member of staff. It was stated that staff were very Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 16 approachable and would listen to any worries. Visitors also said that they would approach staff if they were unhappy with any aspect of care. Neither the home nor the Commission for Social Care Inspection has received any complaints since the last inspection. Inspectors viewed the recruitment files of the 3 most recently appointed members of staff and these gave evidence of a thorough recruitment procedure. References and appropriate checks had been received before staff began work in the home. All new staff sign the company’s policy in respect of the acceptance of gifts. The home does not act as a power of attorney or financial appointee for anyone living there. Small amounts of money are kept safely for some people to ensure they have money to spend in the home and on trips out. The inspectors saw a sample of 4 records and these correlated with amounts held. Receipts are maintained for all purchases. Currently no one outside the home audits these monies but the area manager stated that this is going to be arranged. The home also holds an amenity fund, which again is not audited by anyone outside the home. Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Portcullis House provides a homely environment for the people who live there. Some areas are in need of redecoration and the company is currently addressing this. EVIDENCE: Portcullis House was purpose built in 1970 in a residential area of Langport. The home is split into two areas, one area, Rose Garden, is a specialist home for people who have a dementia. All areas are fitted with a fire detection and call bell system. Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 18 Accommodation is set over two floors with a passenger lift between. There is a variety of communal spaces including pleasant outside areas. The inspectors toured the building and noted that some areas, particularly toilets and bathrooms, are tired looking and in need of refurbishment. There is a refurbishment plan in place, which will include an extension to Rose Garden. All bedrooms are for single occupancy. The inspectors saw that people had been able to bring personal possessions with them to the home which gives rooms an individual feel. The inspectors viewed the laundry. It was tidy with sufficient machines for the size of the home but hand- washing facilities are poor. This was required at the last inspection and there is a plan for the laundry to be refurbished next month, which will include the provision of a separate hand washing sink. Generally the home was clean and well maintained. An unpleasant odour was noted in two bedrooms and this was discussed with the manager at the time of the inspection. Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are clear lines of responsibility and accountability in the home. The recruitment practices minimise the risks of abuse to people living at the home. EVIDENCE: The home employs 34 care staff, 22 (64 ) have a National Vocational Qualification (NVQ) in care at level 2 or above. 11 Non care staff are also employed. (Figures taken from Annual Quality Assurance Assessment) Since the last inspection the home has reviewed staffing levels and additional care and activity staff hours have been made available. The home is currently recruiting staff and has an open day at the beginning of next month. There is a staffing structure in the home, which gives clear lines of accountability and responsibility to staff. There is always a senior member of staff on duty who supervises and supports less experienced staff. Staff spoken to stated that there were opportunities to undertake training specific to their roles. Records given to the inspectors show that all staff have completed Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 20 training in health and hygiene, fire safety, manual handling and health and safety. Many of the staff have received training specific to the needs of the people living at the home, including dementia awareness. There is an ongoing programme of training in issues relating to dementia for staff working in Rose Garden. The inspector viewed the recruitment records of the three most recently employed members of staff. These gave evidence of a thorough recruitment process and all contained all information required to minimise the risks of abuse to people living at the home. Recruitment records show that all new staff undertake a programme of induction when they begin work at the home. This includes mandatory training in health and safety matters. As previously stated the inspector observed that staff interacted and assisted people in a kind and respectful manner. People living in Rose Garden and the main part of the home said that staff were ‘kind’ ‘approachable’ and ‘always happy to help.’ Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is currently no registered manager but the home is being effectively managed by the newly appointed manager. The quality assurance systems in place demonstrate a genuine commitment to ongoing improvement to raise the standard of care for people living at the home. EVIDENCE: There is currently no registered manager at the home. A manager has been employed and has begun the process of applying to the Commission for Social Care Inspection to be registered. A more experienced registered manager from Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 22 another home, belonging to the same company, is supporting the new manager on a weekly basis. The manager and the area manager were available throughout the day. All records requested were made available, all were well maintained and up to date. The company, Somerset Care, has various quality assurance measures in place and has a commitment to ongoing improvement. There are regular meetings for people living and working at the home, which are an opportunity to share information and ideas. The home also sends out surveys on a six monthly basis to seek peoples’ views and identify areas that require improvements. The manager carries out audits on care plans, medication and accidents. They have also begun undertaking mapping exercises (close observation of areas of the home looking at staff interactions and the well being of people living there) to further develop staff skills and raise standards of care. The area manager visits the home on a regular basis and reports on their findings in line with regulation 26 of the Care Homes Regulations 2001. The home does not act as a power of attorney or financial appointee for anyone living there. Small amounts of money are kept safely for some people to ensure they have money to spend in the home and on trips out. The inspectors saw a sample of 4 records and these correlated with amounts held. Receipts are maintained for all purchases. Currently no one outside the home audits these monies but the area manager stated that this is going to be arranged. The home also holds an amenity fund, which again is not audited by anyone outside the home. Systems are in place to ensure the health and safety of people living and working at the home. The inspectors saw evidence that equipment, including the fire detection system, is regularly tested and serviced by outside contractors. All accidents that occur in the home are recorded. These records were viewed and it was noted that although some records documented the treatment that was given to the person, some did not have this information recorded. This was a requirement of the last inspection and has not been fully complied with. As inspectors toured the home it was noted that disposable gloves were freely available in many areas including the Rose Garden. This poses a potential risk to people. The area manager gave assurances that these would be removed and more securely stored as a matter of urgency. An up to date certificate of insurance is displayed in the home. Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 23 Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 2 x x 3 x 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 4 x 3 x 3 2 Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP38 Regulation Schedule 3 (3)(j) Requirement The accident book must record any treatment given to a resident who has had an accident or sustained an injury. (Requirement carried over from last inspection; timescale of 31/12/07 not met) All healthcare assessments must be correctly completed to ensure that people receive appropriate care. Timescale for action 15/06/08 2 OP8 12 (1) [a][b] 30/06/08 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 OP18 OP21 Good Practice Recommendations Staff should receive additional training in the protection of vulnerable adults to ensure that they are up to date with current procedures and practices. Toilets and bathrooms should be redecorated to ensure they provide homely and hygienic facilities. DS0000016076.V359760.R01.S.doc Version 5.2 Page 26 Portcullis House 3 4 OP35 OP38 Monies held at the home should be regularly audited by an independent person . Disposable gloves should be securely stored to minimise the risk of accidents. Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Portcullis House DS0000016076.V359760.R01.S.doc Version 5.2 Page 28 - 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!