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Inspection on 30/10/06 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 30th October 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 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 30th October 2006 2:00 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.V318107.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.V318107.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.V318107.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. 22nd February 2006 Date of last inspection Brief Description of the Service: Elizabeth Peters House is a small home for five older people who have a mental health problem or dementia. 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 was one vacancy 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.V318107.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day in November 2006. The Registered Manger was not at the home but the Responsible Individual for the home was so the inspector spent time with her, staff and speaking with service users. The inspector examined records, all medication and toured the building. Service users are happy at the home and said they liked staff and their rooms. They said they had no problems. The standards of care at this home are good and many of the standards that are not met are because of problems with procedures and systems and not because service users are unhappy. What the service does well: What has improved since the last inspection? Elizabeth Peters Residential Care Home DS0000025593.V318107.R01.S.doc Version 5.2 Page 6 • • • There is a new kitchen and laundry area. There is a new area for service users to make their own drinks and snacks. There is a new manager. 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.V318107.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.V318107.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&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 the needs of service users before they are offered a place at the home. Service users 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: Senior staff meet with services users and conduct an assessment of their needs before someone is offered a place at the 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 Elizabeth Peters Residential Care Home DS0000025593.V318107.R01.S.doc Version 5.2 Page 9 the home permanently and there is a trial period when someone does moves to the home. Elizabeth Peters Residential Care Home DS0000025593.V318107.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 service users’ needs are met. Risks are assessed but plans are not always put in place to make sure that any risks are managed which means that service users may not be kept safe. Staff support service users 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 but stock checks of how much medication is in the home are not effective. EVIDENCE: There was a previous requirement that registered provider must ensure that care plans cover all relevant aspects of service users lives, and that the chosen Elizabeth Peters Residential Care Home DS0000025593.V318107.R01.S.doc Version 5.2 Page 11 care planning system is appropriately used. Service users have plans that show what staff will do to support them in all areas of their life. Service users sign these plans and they are reviewed regularly. There are still different formats for the care plans in some files and they are not all being completed consistently. (See Requirement 1) Although a risk assessment and management plan had been put in place for one service user whose physical needs had increased significantly, another service user has significantly increased mental health needs and staff are concerned about their safety. The risks had been identified in the file but no plan had been put in place to manage those risks. (See Requirement 2) Staff talked about service users’ health and personal care needs and showed they understood what service users wanted. Medication stocks ands records were checked and some stocks of medication did not tally with the records. There were no gaps in the staff signatures for when medication is given. There is a need for a list of all staff who have been trained and deemed as competent to administer medication. (See Requirements 3 & 4) Staff talked about how they try to make sure service users have privacy and are treated with respect. Service users said staff were friendly and caring. Elizabeth Peters Residential Care Home DS0000025593.V318107.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): 11, 12, 13 & 14 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. EVIDENCE: Staff said that they can go out with or without staff when they choose to. Records show that service users are supported to do a variety of things in the week. The Registered Individual and staff talked about how staff try to support service users to stay in touch with their families if they choose to. There are residents meetings and the minutes showed that service users are given information and asked about what they want. Elizabeth Peters Residential Care Home DS0000025593.V318107.R01.S.doc Version 5.2 Page 13 Staff cook for most of the service users and records are kept of what they eat each day. Service users said that the food was ok and they get what they want. Elizabeth Peters Residential Care Home DS0000025593.V318107.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 service users and take their comments and concerns seriously but don’t always record service users comments on the service which means they can’t show that they are always trying to make things better for service users. Service users are protected from harm by staff receiving training and understanding what to do if they think a service user is being abused. EVIDENCE: Records are kept of formal complaints although there have not been any formal complaints since the last inspection. Service users use the surveys or day-to-day conversations with staff to let them know what they maybe dissatisfied with. Service users told the inspector that they had no problems with the home. One recent informal complaint from a service user had not been recorded anywhere. (See Requirement 5) Staff have been on training around protecting vulnerable adults from abuse. Staff could describe the procedures in place to protect service users and what staff should do if they thought a service user was being abused. Elizabeth Peters Residential Care Home DS0000025593.V318107.R01.S.doc Version 5.2 Page 15 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 & 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. Service users have their own rooms that they like and the communal areas are large enough. EVIDENCE: There were previous requirements that the Registered Person must instigate a significant amount of refurbishment, maintenance and re-decoration work to ensure that the home remains suitable for its purpose, and must develop a programme of routine maintenance and renewal and that the registered provider must ensure that requirements and recommendations of the environmental health department are met and implemented. This work has all now been done and there is a new kitchen and laundry area. Elizabeth Peters Residential Care Home DS0000025593.V318107.R01.S.doc Version 5.2 Page 16 On the day of the inspection the home was clean and hygienic throughout. Service users have their own rooms that have been decorated as they choose. Service user 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 not yet been done but the Registered Individual said that they were due to come to the home at the end of November. (See Recommendation 2) Elizabeth Peters Residential Care Home DS0000025593.V318107.R01.S.doc Version 5.2 Page 17 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 adequate. 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 service users. Staff hold the right qualifications and get enough training which means that service users are cared for by people who know what they are doing. Recruitment procedures are not effective enough which means that the organisation is not doing enough to check up on the people who work in the home or to make sure that it is getting staff who can do the job which means that service users may be being put at some risk. EVIDENCE: There are at least two staff on duty at all times although is may be changing in the future to better reflect the lower needs of service users at some times of the week. The Registered Manager will consult with the Commission before any changes are made. All staff hold or are undertaking the NVQ Level 2, 3 or 4 in Care. Elizabeth Peters Residential Care Home DS0000025593.V318107.R01.S.doc Version 5.2 Page 18 There were several previous requirements around the recruitment procedures. The inspector had checked the systems for recruitment at another of the organisation’s homes and found the following problems: The application form does not ask for a full employment history and so gaps in employment could not be investigated. Records were not maintained of all interviewers’ notes and comments on interviewees’ performances. References were not always stamped by the organisation or on headed notepaper. Although the home applies for new Criminal Records Bureau checks on all staff, it is currently using the POVAFirst check as a matter of course, which is only supposed to be used for emergencies. The home does not destroy CRB checks after six months (or when the inspector has had the opportunity to see the checks) and then keep a central record of the dates of the CRB checks. There was a previous recommendation that an interview format is developed that demonstrates interviews are conducted in accordance with equal opportunities policies. This has not yet been done. (See Requirements 6 - 10) There was a previous requirement that the registered provider must ensure that the homes training plan meets mandatory requirements, sector skills specifications and is based on the assessed needs of staff and the needs of service users. The Responsible Individual did not know if there was a training plan or where the training plan was and said she would send it on to the Commission after the inspection. (See Requirement 11) The induction and foundation programme for the home has been updated but although the workbooks and training information being used by the organisation is that of TOPSS which is the organisation now called Skills For Care. This means that although the induction and foundation programme is almost in line with requirements, there will be a more up-to-date version of the guidelines that should be used. (See Requirement 12) Annual appraisals have not been carried out so the training plans have not been drawn up following a full assessment of their work performance and training needs. (See Requirement 13). Although the staff team has recently had some mental health training from another manager within the organisation who is a registered nurse, there may be more opportunities for the Registered Manager to offer in-house training to staff during team meetings or to access external training. The Registered Manager said they have done this at the home before and it had been very useful. (See Recommendation 1) Elizabeth Peters Residential Care Home DS0000025593.V318107.R01.S.doc Version 5.2 Page 19 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, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although there are lots of checks in place at the home there is no systems that looks at developing the home and planning to make things better for service users each year which means that things do not change much for service users. Staff do not receive an annual assessment of their work performance and individual training needs which means that staff may not be receiving the training that best makes sure they can do their job better. Service users are protected from harm by the effective operation of all health and safety procedures apart from the weekly fire system checks. Elizabeth Peters Residential Care Home DS0000025593.V318107.R01.S.doc Version 5.2 Page 20 EVIDENCE: There was a previous requirement that the Registered Person must ensure that there is a full-time or full-time equivalent Registered Manager/s in post. This has now been done and they have been successfully interviewed for Registered Manager by the Commission. There was a previous recommendation that surveys of the views of service users and relatives be specifically designed for each purpose. Surveys do get carried out and although there is a thorough system of checks and information gathering in place in the home there is not yet a system that looks forward at planning how the home will improve in the next year in order to make things better for service user and there isn’t yet a plan in place based on what service users want. (See Requirement 14) Although the required monthly checks of the home by the Responsible Individual are being carried out, the Commission’s records showed that these are not being received regularly by the Commission. (See Requirement 15) It was not possible to assess how regularly staff receive supervision as records were not available. (See Requirement 16) There was a previous requirement that the registered provider must ensure that the times of fire drills are recorded. All health and safety documentation and checks were in place and in order apart from some weekly fire system checks that had been missed. (See Requirement 17). There were no health and safety problems noted on the tour of the building. Elizabeth Peters Residential Care Home DS0000025593.V318107.R01.S.doc Version 5.2 Page 21 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 X X 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X 2 X 2 Elizabeth Peters Residential Care Home DS0000025593.V318107.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15 Requirement The Registered Manager must ensure that the chosen care planning system is appropriately used. Part of previous requirement: Unmet timescales 30/11/04, 30/04/05, 31/12/05 & 31/05/06 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. The Registered Manager must ensure that the medication stock checking systems are effective. 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. 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. DS0000025593.V318107.R01.S.doc Timescale for action 31/12/06 2. OP7 15 & 13 (4) (a) & (c) 30/11/06 3. 4. OP9 OP9 13 (2) 13 (2) 13/11/06 30/11/06 5. OP16 OP33 22 30/11/06 Elizabeth Peters Residential Care Home Version 5.2 Page 23 6. OP29 19 (1) & (4) 7. OP29 19 (1) & (4) 13 (6) 8. OP29 9. OP29 13 (6) 10. OP29 13 (6) & 17 (2) 11. OP30 18 (1) (c) (i) 18 (1 (c) (i) 12. OP30 13. OP30 OP36 18 (2) 14. OP33 24 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. The Registered Individuals must ensure that records are kept of all interviewers notes and decisions. The Registered Individuals must ensure that effective measures are taken to verify the source of all staff references. The Registered Individuals must ensure that the POVAFirst check is only used in emergencies and not as a matter of course. The Registered Individuals must ensure that CRB checks are destroyed after six months or when the inspectors have had the opportunity to see them and that a central record is then maintained of the CRB date and number. The Registered Individuals must ensure that the training plan for the home (if there is one) is sent through to the Commission. The Registered Individuals must ensure that the induction and foundation programme being used is the most up-to-date version of the Skills For Care (and not TOPSS) programme. 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. The Registered Individuals must ensure that there is a forward looking quality assurance system in place in the home that is DS0000025593.V318107.R01.S.doc 31/01/07 31/01/07 31/01/07 31/01/07 31/01/07 30/11/06 31/12/06 31/12/06 31/01/07 Elizabeth Peters Residential Care Home Version 5.2 Page 24 15. OP33 26 (3) 16. OP36 18 (2) 17. OP38 23 (4) (c) based on the views of service users and which focuses on a process of continuous improvement. The Registered Individual must perform monthly unannounced visits to the home and submit reports of the visits to the CSCI. The Registered Manager must ensure that the timetable of supervisions carried out is sent through to the Commission. The Registered Manager must ensure that weekly fire system checks are carried out as planned. 30/11/06 30/11/06 14/11/06 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. Refer to Standard OP30 Good Practice Recommendations 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 It is recommended 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. Previous recommendation. 2. OP22 Elizabeth Peters Residential Care Home DS0000025593.V318107.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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.V318107.R01.S.doc Version 5.2 Page 26 - 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. 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