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Inspection on 12/06/07 for Elizabeth Peters Residential Care Home

Also see our care home review for Elizabeth Peters Residential Care Home for more information

This inspection was carried out on 12th June 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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Elizabeth Peters Residential Care Home 22 Newquay Road Catford London SE6 2NS Lead Inspector Lisa Wilde Unannounced Inspection 11:00 12 June & 9th July 2007 th 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 Elizabeth Peters Residential Care Home DS0000025593.V341544.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. Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elizabeth Peters Residential Care Home Address 22 Newquay Road Catford London SE6 2NS 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) 0208 244 0013 0208 244 0013 nudyworld@hotmail.com Elizabeth Peters Care Homes Limited Mrs Judith Dongwe Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home can only accommodate service users aged 50 years and older. As agreed on 26th July 2006, one named service user under the age of 50 years, with a mental disorder, can be accommodated. The CSCI must be informed when this service user no longer resides at the home. 30th October 2006 Date of last inspection Brief Description of the Service: Elizabeth Peters House is a small home for five older people who have mental health problems. The home is one of four owned and managed by a local provider, Elizabeth Peters Care Homes Ltd. The home is in a quiet residential street close to the centre of Catford. The home is well served by public transport facilities with bus and train services within a short walking distance of the home. There is a small parade of shops close by, with larger shops and facilities available in Catford town centre. There were no vacancies on the day of the inspection. The range of fees for a place at the home was not available at the time of writing the draft report. The home makes the reports of the Commission’s inspections available to service users in the hallway of the home. Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day in June 2007 and the inspector then waited for the managers to send on further written information. The inspector met with residents, staff and the Responsible Individual. The Registered Manager was not at the home. The inspector toured the building, looked through records and checked the medication stocks. The inspector found that again this home provides a high standard of care and residents said they were happy at the home with no problems. Most of the requirements made at the last inspection had been met although a few more were made during this inspection. What the service does well: The standards assessed at this inspection showed that: • • • • Staff make sure that they can meet people’s needs before they are offered a place at the home. People can come to the home to look round and stay overnight before they decide to move their permanently. Staff write care plans that describe what they will do to make sure that all service users’ needs are met. Staff support residents in different ways and service users are encouraged to attend regular GP and clinic appointments to make sure they stay healthy. Medication is given to service users as required. Service users are supported to do what they want to do and go out when they want to. Service users choose what they want to eat and staff cook for them. Staff listen to service users and take their comments and concerns seriously Service users are generally protected from harm by staff receiving training about what to do if they think a service user is being abused The home is comfortable, clean and homely throughout. DS0000025593.V341544.R01.S.doc Version 5.2 Page 6 • • • • • • Elizabeth Peters Residential Care Home • Service users have their own rooms that they like and the communal areas are large enough. Staff receive regular supervision and an annual assessment of their work performance and individual training needs. Service users are protected from harm by the effective operation of all health and safety procedures. • • 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. The summary of this inspection report can be made available in other formats on request. Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 7 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 Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 8 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): 2, 3, 4 & 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff make sure that they can meet people’s needs before they are offered a place at the home. People can come to the home to look round and stay overnight before they decide to move their permanently. Standard 6 is not applicable as the home does not provide intermediate care. EVIDENCE: Residents have contracts with the organisation that they have read and signed. One person has moved to the home since the last inspection and their assessment and files were examined. Senior staff meet with residents and conduct an assessment of their needs before someone is offered a place at the Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 9 home. Information is gathered and the assessment is written down. Service users are offered chances to visit the home for day, overnight and weekend stays before they decide to move to the home permanently and there is a trial period when someone does moves to the home. The managers and staff have concerns about one resident who has begun to have falls but whose bedroom is on the first floor. They do not feel they are safe at the home because of this and other conditions. (See Requirement 1) Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 10 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 adequate This judgement has been made using available evidence including a visit to this service. Staff write care plans that describe what they will do to make sure that all residents’ needs are met. Staff support residents in different ways and residents are encouraged to attend regular GP and clinic appointments to make sure they stay healthy. Medication is given to residents as required but stock checks of how much medication is in the home are not effective. EVIDENCE: There was a previous requirement that the Registered Manager must ensure that the chosen care planning system is appropriately used. The same care plan format is now used for all residents and all needs are covered in them. Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 11 There was a previous requirement that the Registered Manager must ensure that when risks change or increase a risk management plan is drawn up to show how staff will safely manage those risks. These are now being done although the computer files did not show dates and so it could not be established if they were being reviewed every month. Some care plans are held on the computer but not all staff can access the computer files. (See Requirements 2 & 3) There was a previous requirement that the Registered Manager must ensure that the medication stock checking systems are effective. The homely remedies records did not match the number of tablets. (See Requirement 4) The was a liquid medication being used that was significantly lower than it should have been according to how much should have bee used. (See Requirement 5) There was a previous requirement that the Registered Manager must ensure that there is held a list of all staff who have been trained and judged as competent to administer medication which includes an example of their initials signature. This was not yet in the file. (See Requirement 6) Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 12 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. Residents are supported to do what they want to do and go out when they want to. Residents choose what they want to eat and staff cook for them. EVIDENCE: Staff said that they can go out with or without staff when they choose to. Records show that residents are supported to do a variety of things in the week. The Registered Individual and staff talked about how staff try to support residents to stay in touch with their families if they choose to. There are residents meetings and the minutes showed that residents are given information and asked about what they want. Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 13 Staff cook for most of the residents and records are kept of what they eat each day. Residents said that the food was very good and they get what they want, if they don’t want something that is made then staff will make them something else. The menus are varied but perhaps not quite as healthy as they could be. (See Recommendation 1) Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 14 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 adequate This judgement has been made using available evidence including a visit to this service. Staff listen to residents and take their comments and concerns seriously but don’t always record residents’ comments on the service which means they can’t show that they are always trying to make things better for residents. Residents are generally protected from harm by staff receiving training about what to do if they think a resident is being abused but showed that they would benefit from more training to fully understand all the issues. EVIDENCE: There was a previous requirement that the Registered Manager must ensure that a record is kept of all informal complaints and concerns of residents along with any action taken to address the problem. The Registered Individual said that there had been no complaints and records showed this but records of dayto-day concerns are not yet being maintained. (See Requirement 7). Staff discussed their recent safeguarding adults training and what they would do if they suspected abuse. They showed that they needed further training in the required procedures to effectively protect and investigate issues. (See Requirement 8) Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 15 The Registered Individual and staff do not yet have an awareness of the new Mental Capacity Act and its effect on assessing resident’s capacity to make decisions. (See Requirement 9) Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 16 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, 22, 23, 24, 25 & 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is comfortable, clean and homely throughout. Residents have their own rooms that they like and the communal areas are large enough. EVIDENCE: There is a lounge with separate dining area, an area for residents to make drinks and snacks and a separate kitchen. The laundry area is separate to the kitchen. On the day of the inspection the home was clean and hygienic throughout. Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 17 Residents have their own rooms that have been decorated as they choose. Residents said they were happy with their rooms. There was a previous recommendation that an assessment of the premises and facilities be made, by suitably qualified persons including an occupational therapist with specialist knowledge of the client groups catered for, to ensure that disability equipment is provided and environmental adaptations are made to meet the needs of service users. This has been done and there have been certain rails added and a new seat in the bath. Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 18 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 enough staff on duty to meet the needs of residents and they hold the right qualifications and get enough training which means that residents are cared for by people who know what they are doing. Recruitment procedures are now effective enough which means that the organisation is doing enough to check up on the people who work in the home and to make sure that it is employing staff who can do the job. EVIDENCE: There was a previous requirement that the Registered Individuals must ensure that the staff application form asks for a full employment history and that any gaps in employment are investigated with records of that investigation being kept. There was a previous requirement that the Registered Individuals must ensure that records are kept of all interviewers notes and decisions. This is now being done. There was a previous requirement that the Registered Individuals must ensure that effective measures are taken to verify the source of all staff references. Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 19 This is now being done although no reference had been gained from the most recent employer and there was no explanation in the recruitment pack as to why. (See Requirement 10) There was a previous requirement that the Registered Individuals must ensure that the POVAFirst check is only used in emergencies and not as a matter of course. This no longer occurs. There was a previous requirement that the Registered Individuals must ensure that the training plan for the home (if there is one) is sent through to the Commission. This has been redone and is thorough and covers the individual needs of all staff. There was a previous requirement that the Registered Individuals must ensure that the induction and foundation programme being used is the most up-todate version of the Skills For Care (and not TOPSS) programme. The new programme is in place although there have been no new staff yet to start using it. There was a previous requirement that the Registered Individuals must ensure that all staff have an at least annual appraisal of their work performance and training needs and that individual training plans are drawn up following these appraisals. These are now being done. There was a previous recommendation that the Registered Individuals should consider ways in which in-house training can be offered to staff around mental health issues and should look into accessing more external training for staff in this area. This has not yet been done. (See Recommendation 2) Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is now a thorough system that looks at developing the home and planning to make things better for residents each year. Staff receive regular supervision and an annual assessment of their work performance and individual training needs which means that staff are receiving the support and training that best makes sure they can do their job better. Residents are protected from harm by the effective operation of all health and safety procedures. Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 21 EVIDENCE: There was a previous requirement that the Registered Individuals must ensure that there is a forward looking quality assurance system in place in the home that is based on the views of service users and which focuses on a process of continuous improvement. There has been a lot of work over the past year on drawing up a quality assurance programme for the home that covers all the areas of the service. It now meets the standard although it hasn’t yet been fully used and the information is still as it was last year, although work is being done to collate and start to transfer the information. There was a previous requirement that the Registered Individual must perform monthly unannounced visits to the home and submit reports of the visits to the CSCI. These are being done and now no longer need to be sent through to the Commission each month but they are not being kept at the home. (See Requirement 11) There was a previous requirement that the Registered Manager must ensure that the timetable of supervisions carried out is sent through to the Commission. This has been done and shows that staff receive regular supervision, Staff confirmed this and said that it was useful and supportive. There was a previous requirement that the Registered Manager must ensure that weekly fire system checks are carried out as planned. This is now being done. Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 22 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 X 3 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 3 3 3 X 3 Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 23 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 OP4 Regulation 12 (1) Requirement The Registered Manager must ensure that the home can fully meet the needs of the service user who is currently in hospital should they return to the home and demonstrate how they will keep them safe in the physical environment. This assessment and management plan must be sent to the Commission. The Registered Manager must ensure that all risk assessments are updated every month as required. The Registered Manager must ensure that if care plans are to be written on the computer, that everyone has the ability to access those plans. The Registered Manager must ensure that the medication stock checking systems are effective. Previous requirement: Unmet timescale 13/11/06 The Registered Manager must ensure that liquid medications are dispensed accurately. The Registered Manager must ensure that there is held a list of DS0000025593.V341544.R01.S.doc Timescale for action 10/07/07 2. OP7 15 (2) (b) 10/07/07 3. OP7 15 (2) 10/07/07 4. OP9 13 (2) 10/07/07 5. 6. OP9 OP9 13 (2) 13 (2) 10/07/07 10/07/07 Elizabeth Peters Residential Care Home Version 5.2 Page 24 7. OP16 22 8. OP18 18 (1) (c) (i) 18 (1) (c) (i) 9. OP18 10. OP29 19 (1) & (4) 11. OP33 26 (3) all staff who have been trained and judged as competent to administer medication which includes an example of their initials signature. Previous requirement: Unmet timescale 13/11/06 The Registered Manager must ensure that a record is kept of all informal complaints and concerns of service users along with any action taken to address the problem. Previous requirement: Unmet timescale 30/11/06 The Registered Manager must ensure that all staff understand the correct procedure to follow if abuse is suspected or reported. The Registered Individuals must ensure that an appropriate policy and procedure is drawn up regarding the mental capacity act, that staff are aware of the effect of this and that effective assessments of capacity are conducted when necessary. The Registered Individuals must ensure that a reference is gained from the most recent employer where possible or an explanation as to why this is not done is kept on file. The Registered Individual must keep records in the home of the monthly unannounced visits. 31/08/07 31/08/07 30/09/07 31/08/07 31/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 25 1. 2. OP15 OP30 The Registered Manager should ensure that staff think about creative ways to introduce more fruit and vegetables into meals. The Registered Individuals should consider ways in which in-house training can be offered to staff around mental health issues and should look into accessing more external training for staff in this area. Previous recommendation Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH 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 Elizabeth Peters Residential Care Home DS0000025593.V341544.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!