Inspection on 12/12/05 for Pat Shaw House

This inspection was carried out on 12th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pat Shaw House 24/05/06

Pat Shaw House 23/05/05

Pat Shaw House 27/10/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Pat Shaw House 50 Globe Road Bethnal Green London E1 4DS Lead Inspector Nurcan Culleton Unannounced Inspection 12th December 2005 11:00 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 Pat Shaw House DS0000052367.V272535.R01.S.doc Version 5.0 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. Pat Shaw House DS0000052367.V272535.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pat Shaw House Address 50 Globe Road Bethnal Green London E1 4DS 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) 0207 702 7500 0207 790 1281 Excelcare Holdings Mrs Audrey Parathan Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Pat Shaw House DS0000052367.V272535.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd May 2005 Brief Description of the Service: Pat Shaw House is a residential home, which offers care and support for up to 38 older persons. Whilst the home is registered to take 40 persons, two rooms are used for staffing and storage purposes. The home is located in the Stepney area off Mile End Road in the London Borough of Tower Hamlets. It is within a short distance to the city, Mile End, Royal London Hospital and Stepney Green and is close to local shops and amenities. There are good bus and rail links. The home has 32 bedrooms with toilets and hand-basins and 6 en-suite bedroom flats located on three floors. All rooms are spacious, clean and are wheelchair accessible. There are specialist facilities to assist disabled service users. The rooms are located on three floors. There are communal rooms for service users use on each floor. There is also a small garden with patio. Pat Shaw House DS0000052367.V272535.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on 12th December 2005. The Registered Manager and Regional Operations Manager were present during the inspection. The inspector spoke to several members of staff and service users as part of the consultation process of the inspection. The inspector also examined the home’s written documentation, including service users’ assessments and care plans and toured the home. Thirty five service users were resident in the home at the time of inspection. In addition to a range of standards inspected, the inspector reviewed 16 requirements made at the last inspection. What the service does well: What has improved since the last inspection? What they could do better: Three new requirements are given concerning 1. The need to store away incontinence pads to preserve service users’ privacy and dignity. 2. To improve the lighting in the hallways and 3. To ensure correct recording of service users’ personal allowance money. Five recommendations are also given to encourage continuing good practices in the home. Pat Shaw House DS0000052367.V272535.R01.S.doc Version 5.0 Page 6 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. Pat Shaw House DS0000052367.V272535.R01.S.doc Version 5.0 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 Pat Shaw House DS0000052367.V272535.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5, 6 Prospective service users and their relatives are provided with sufficient information to make an informed choice about living in the home. Service users’ needs are fully assessed prior to admission. The home has evidenced that it is able to meet service users’ needs. EVIDENCE: The inspector viewed the home’s Statement of Purpose and Service User Guide. The documents contained all the information required by regulation. The inspector recommends that range of needs that the home is intended to meet is specified in the admissions criteria. A minor amendment to the complaints procedure contained within the Statement of Purpose was made as required at the last inspection. Pre-admission assessments were viewed in service users’ files and were satisfactory, containing necessary personal background and health needs information required to assess the suitability of the home. The home also uses a Pre-admission Care Diary, completed with the service user and family/representative, identifying personal information such as employment history, hobbies, likes, dislikes and special memories. Pat Shaw House DS0000052367.V272535.R01.S.doc Version 5.0 Page 9 The inspector recommends that prospective service users or their representatives sign to evidence any documents given to them, such as such the Statement of Purpose, Service Users’ Guide and complaints procedure. Pat Shaw House DS0000052367.V272535.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 Service users’ health, personal and social care needs are clearly outlined in individual care plans and health needs are being met. Staff are well regarded by service users. The home has reviewed its policies and practises concerning service users’ right to privacy. EVIDENCE: Service user care plans were examined. These were comprehensive, outlining service users’ individual needs on separate pages, their goals and actions needed. Each need was reviewed on a monthly basis, irrespective of whether needs had changed. A previously made requirement for all service users to sign their care plans were met. The inspector viewed evidence of health appointments attended by service users, verbal and written and communication with health professionals. Service users spoke highly of staff and informed that they were treated with respect. A consent form was available in each file for service users who wished to have their own keys, meeting another previously made requirement. An issue of the privacy of service users was raised at the last inspection concerning maintenance and night staff entering service users’ rooms. The Registered Manager spoke with the service user affected, staff and the maintenance workers. Service users are offered the choice of signing a disclaimer form should they wish not to be checked on at night. Pat Shaw House DS0000052367.V272535.R01.S.doc Version 5.0 Page 11 All files now contain signed statements by service users confirming their views on death and dying including funeral arrangements. Service user risk assessments were satisfactory. A requirement is given to ensure that incontinence pads are stored away from view to preserve the privacy and dignity of service users. Pat Shaw House DS0000052367.V272535.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Service users’ social, cultural, religious and recreational needs are being facilitated. Service users maintain regular contact with family and friends. The home provides a balanced, wholesome diet in consultation with service users. EVIDENCE: Service users were undertaking physical exercise at the time of inspection. Some service users’ attend a day centre during the week. One service user confirmed she is assisted to go shopping. Evidence of day trips was seen in minutes of the residents’ meeting. Service users’ feedback and records showed contact and visits by family and friends. Specialist dietary needs are met for service users who, for example, require Kosher meals. There were mixed service user views regarding the quality of food. Not all were favourable though consultation with service users concerning food was evident and is ongoing. The inspector recommends that an inventory is completed for all service users to record their personal possessions. Pat Shaw House DS0000052367.V272535.R01.S.doc Version 5.0 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 The home presents as having a positive approach to complaints. Evidence suggests that service users and their relative’s views are listened to, taken seriously and acted upon and that issues raised with management are dealt with promptly and addressed. EVIDENCE: Most service users were satisfied with the staff and living in the home. Most informed the inspector that they had no complaints and that they would inform a member of staff or manager if they did have a complaint. The complaints book was examined and showed that six complaints were appropriately recorded, investigated where necessary with the outcome noted. The complaints policy was amended to specify that service users have the right to approach the CSCI directly. Records were seen to evidence that staff receive training on Adult Protection issues. Service users’ are enabled to vote in elections. Pat Shaw House DS0000052367.V272535.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 The home is clean, pleasant, well-maintained and suitable for its stated purpose. Facilities in the home are sufficient to meet service users needs. Service users are comfortable and have their own possessions around them. Lighting needs to improve in the hallways. Recommendations are given concerning storage of wheelchairs and service users’ satisfaction with their rooms. EVIDENCE: The inspector toured the premises. Rooms seen were clean, tidy, free of odours and homely in décor. There are three bathrooms, one on each floor and one containing a Parker bath on the ground floor. There are also disabled toilets available. Other specialist aids and equipment to assist disabled service users are available, such as hoists, grab rails, commodes and wheelchairs. Service users’ specialist needs are assessed by an occupational therapist. A raised bed and chair was seen in one service users’ room. Service users’ rooms are personalised with furnishings, such as items including a bed, chest of drawers, pictures, televisions and other possessions. Pat Shaw House DS0000052367.V272535.R01.S.doc Version 5.0 Page 15 Most service users reported being satisfied with their rooms however one service user expressed dissatisfaction with her room. All rooms were the same cream colour. Some were quite bare, though one staff member informed this was by the choice of some service users. The inspector recommends that service users’ views are obtained concerning their satisfaction with their rooms, including the colour scheme and whether they wish to make any changes to suit their preferences. The Registered Manager arranged training for staff regarding the use of manually assisted bath as required at the previous inspection. Wheelchairs stored in service users’ ensuite rooms looked unsightly. The Inspector recormmends that an alternative space is sought to accommodate service users’ wheelchairs. The lighting in the hallway on the first and second floor was dark and needs to improve. Water temperatures were in the process of being adjusted at the time of the inspection. Pat Shaw House DS0000052367.V272535.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Evidence shows that service users’ needs are being met by the numbers and skills demonstrated by staff. Progress has been made regarding staff files, evidencing good recruitment and practices and good management of staff files. Staff are offered regular training to ensure they remain competent in their jobs. EVIDENCE: The inspector spoke with staff and service users and inspected staff files. Service users informed that staff were available to meet their needs. Staff informed that there was a good relationship among the staff and between staff and management. There are 18 permanent care staff employed and 5 seniors. 10 bank staff are used to cover staff shortages. At night there is 1 senior carer on duty and 2 wake-in staff members. There are also 3 cooks, 2 cook assistants, 1 kitchen assistant, 1 handyman, 5 cleaners and 1 housekeeper. The Registered Manager informed that the staff group was stable with low sickness, absence and turnover. Staff informed that they had regular training and supervision. A programme of appraisal and development of staff is in place. Staff files were in good order. Files contained all required documentation. Pat Shaw House DS0000052367.V272535.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21, 32, 33, 34, 35, 36, 37 The home is run in the best interests of service users. The home offers a good standard of care, influenced by positive management and leadership. The processes of managing the home are open and transparent and there is good communication between service users, staff and the management of the home. EVIDENCE: The Registered Manager has an NVQ Level 3 and is waiting to be awarded the NVQ Level 4 in management and care. The Registered Manager had experience of work as a carer and senior carer in the home for several years prior to managing the home. She has also had previous experience of managing a care home for people with mental health problems. The Registered Manager demonstrated an intimate knowledge and clear understanding of the health, safety and welfare of services users and staff. All service users spoken to praised the staff and management of the home. The inspector observed a good relationship among service users and staff, underlying a positive ethos, leadership and management approach of the home. Pat Shaw House DS0000052367.V272535.R01.S.doc Version 5.0 Page 18 Staff expressed satisfaction with the Registered Manager informing that she was supportive and helpful to them. A sample of four service users’ personal allowances were checked. Three accounts were correct however one was incorrect. In this case, an extra five pounds was counted for the service user compared with the recorded balance in her account book. The Registered Manager must ensure that all financial accounts concerning service users are accurately recorded. Pat Shaw House DS0000052367.V272535.R01.S.doc Version 5.0 Page 19 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 2 x 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 1 11 3 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 3 18 3 3 3 3 2 3 2 1 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 x Pat Shaw House DS0000052367.V272535.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? no 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 OP10 Regulation 12 4(a) Requirement Timescale for action 20/01/06 2 OP25 23(p) 3 OP35 17 The Registered Manager must ensure that incontinence pads are stored away from view to ensure service users’ privacy and dignity. The Registered Manager must 20/01/06 ensure that the lighting in the hallway on the first and second floor is improved. The Registered Manager must 20/01/06 ensure that all financial accounts concerning service users are accurately recorded. Pat Shaw House DS0000052367.V272535.R01.S.doc Version 5.0 Page 21 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 OP1 Good Practice Recommendations The inspector recommends that the home specifies the range of needs that the home is intended to meet in the admissions criteria. The inspector recommends that service users or their representatives sign to evidence any documents given to them, such as such the Statement of Purpose, Service Users’ Guide and complaints procedure. The inspector recommends that an inventory is completed for all service users to record their personal possessions. The Inspector recormmends that an alternative space is sought to accommodate service users’ wheelchairs. The inspector recommends that service users’ views are obtained concerning their satisfaction with their rooms, including the colour scheme and whether they wish to make any changes to suit their preferences. 2 OP1 3 4 5 OP14 OP24 OP24 Pat Shaw House DS0000052367.V272535.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pat Shaw House DS0000052367.V272535.R01.S.doc Version 5.0 Page 23 - 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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