Inspection on 23/05/05 for Pat Shaw House

This inspection was carried out on 23rd May 2005.

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.

Other inspections for this house

Pat Shaw House 24/05/06

Pat Shaw House 12/12/05

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 Announced Inspection 23rd May 2005 10:00am 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 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 Version 1.10 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 Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7702 7500 020 7790 1281 sam.dunn@excelcareholdings.com 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 Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 27th October 2004 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 ensuite bedroom flats. All rooms are spacious, clean and personalised and are wheelchair accessible. 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 Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place in the afternoon of 23rd May 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. 8 comment cards were received prior to the inspection from service users, staff and relatives and are taken into account in this report. They expressed mostly positive views of the home. The inspector also examined the home’s written documentation, including service users’ assessments and care plans and toured the home. What the service does well: What has improved since the last inspection? The home has shown significant progress in most areas of service provision and particularly in records available, as required by regulation. Out of 17 previous requirements, all but 4 are restated. Though there have been inconsistencies, two of these requirements concerning 1. care plans being signed by service users and 2. consultation with service users regarding views on death and dying, have been met in part. Consultation on these issues are evidenced in service user files. The home has taken on board the issues arising out of the last inspection and are systematically action planning to meet the required standards. These include improvements in a broad range of documentation, care practises and in the improved relationship between staff and service users. The Registered Manager acknowledged the areas needing improvement and demonstrated plans to train staff in new improved procedures, particularly regarding assessments (dependency, risk assessments) on a gradual, phased basis. Pat Shaw House Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pat Shaw House Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Pat Shaw House Version 1.10 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 standard(s) 1, 2, 3, 4, 5 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 assessed prior to admission. All service users are provided with contracts and other documents relating to services in the home. EVIDENCE: The inspector viewed the home’s Statement of Purpose and Service User Guide. The documents contained all the information required by regulation, meeting a previous requirement concerning the content of these documents. A minor amendment is required however to the complaints procedure contained within the Statement of Purpose. This is to specify that service users have the right to complain to the CSCI directly. These documents were seen by the inspector in service users’ rooms. 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. Pat Shaw House Version 1.10 Page 9 Two separate dependency forms are in use and must be amalgamated. The inspector was informed that the Pre-admission and dependency form is the updated form and staff are being trained how to use it. New requirements: 1.The amended complaints procedure must be incorporated into the Statement of Purpose. 2. The home must use one service user dependency form and staff must be trained on how to complete and implement the form. Pat Shaw House Version 1.10 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 standard(s) 7, 8, 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 held in high regard by service users. The home must review its policies and practises concerning service users’ right to privacy and confidentiality. EVIDENCE: Service user care plans were viewed and were comprehensive, outlining service users’ individual needs and actions required. One previous requirement concerning care plans was met, another partly met. Newly formatted care plans are now being implemented. There was evidence of consultation with service users concerning their care plans and most care plans were signed by service users and their key workers, however this was not always consistent. Some needs identified in individual care plans were not signed by service users. The inspector viewed evidence of health appointments attended by service users, verbal and written and communication with health professionals. There was evidence of a district nurse visiting regularly to monitor and advise on pressure sores. Service users spoke highly of staff and informed that they were treated with respect. Whilst some service users spoken to had keys to their rooms, this did not apply to all. The inspector saw no lockable cabinets. One service user expressed a wish for a lockable cabinet and his own key. Pat Shaw House Version 1.10 Page 11 This service user was also dissatisfied that on some occasions he would lock his door from the inside, however he would find by the morning that the door had been opened by the night staff. Furthermore, one person, thought to be a maintenance man, had walked into his room when he was lying down without knocking on the door. Not all files contained evidence of signed statements by service users confirming their views on death and dying including funeral arrangements. Service user risk assessments are too narrow and expanded. Outstanding requirements: 1. All needs identified in care plans must be signed by the service user or their family/representative (partly met). 2. Consultation with all service users (and or their family/representative) regarding their views on matters related to death, dying and funeral arrangements must be obtained in writing. New requirements: 1. All service users must be offered the choice to have their own keys and lockable cabinets in their rooms. 2. The home must review its policies and procedures to ensure that service users’ right to privacy and confidentiality is respected at all times. 3. Service user risk assessments must be revised and expanded. Pat Shaw House Version 1.10 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 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 must provide a more balanced, wholesome, fresh diet on the menu at supper time. EVIDENCE: Some service users spoken to wished to have more physical exercise as part of the social activities provided in the home. Two service users confirmed they ate Kosher meals from the local Jewish resource centre. One service user attended the centre during the week. Another informed of being assisted to go shopping. Evidence of planned day trips was seen on the service user notice board and in minutes of the residents’ meeting. Feedback from service users and records showed frequent contact with family and friends, including visits by service users to family. The inspector saw evidence of consultation with service users concerning food. There were mixed service user views regarding the quality of food. Not all were favourable, for example, the quality of ham in sandwiches and sandwiches being too thin. The inspector was dissatisfied with the choice of meals for supper on the menu, most of which was processed. Consultation with service users concerning food was evident and must continue. Records of alternative food choices provided upon request by service users were seen and must also continue and be available for inspection. Pat Shaw House Version 1.10 Page 13 New Requirements: 1. The home must ensure the provision of wholesome, nutritious, fresh food and to ensure that processed foods are not the staple part of the menu. 2. The home must consult (and evidence consultation) with service users regarding their participating in physical exercise in the home. The home must provide or arrange for the provision of physical exercise for service users who wish to undertake such activities. Pat Shaw House Version 1.10 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 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. 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 11 complaints were appropriately recorded, investigated where necessary with the outcome noted. New requirement: The complaints policy must be amended to specify that service users have the right to approach the CSCI directly. This amended policy must be given to all service users and the old policy, as seen in service user rooms, must be removed and discarded. Pat Shaw House Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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. Some repeat and new requirements have been given, predominately for reasons of health and safety. EVIDENCE: Rooms seen were clean, tidy, free of odours and homely in décor. There are a sufficient number of washing facilities and toilets to meet service users’ needs. Specialist equipment is in place, including assisted baths and rails in the bathrooms. Service users’ rooms are personalised with furnishings, such as items including a bed, chest of drawers, pictures, televisions and other possessions. Service users reported being satisfied with their rooms. Carpets had been cleaned as previously required. A staff member complained to the inspector that she found it difficult to manually adjust the assisted bath(s) and requested the provision of alternative equipment. Pat Shaw House Version 1.10 Page 16 Two previous requirements are outstanding: 1. A lampshade is still required in the first floor toilet. 2. The lighting in the hallway downstairs must be improved. New requirements: 1. Water temperatures in the hand basins of some bedrooms were too hot and must be adjusted close to 43 degrees. 2. The water pressure must be adjusted in the basin of the first floor toilet as the water spills over the basin flooding the floor when the tap is switched on. 3. The Registered Manager to consult with staff regarding the manually assisted bath(s); to arrange for either training on the appropriate use of this equipment or, if applicable, to arrange for the assessment and provision of an alternative assisted bath in order to ensure the health and safety of staff. Pat Shaw House Version 1.10 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 Evidence suggests that service users are safe and their needs are met by the numbers and skill mix of staff. Progress has been made regarding staff files, evidencing good recruitment practices and 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 their needs were met by the staff. Staff informed that there was a good relationship among the staff and between staff and management. Comment cards received prior to the inspection informed that service users and relatives believed there were sufficient numbers of staff on duty. One member of staff and a relative however wrote that staff stress levels rise when having to cover for sickness and shortage of staff. The management team advised there are usually 2 staff members for each floor on each shift and that most service users required minimal support or supervision with their personal care. Bank staff are used to cover staff shortages. Staff informed that they had regular training and supervision. A programme of appraisal and development of staff has begun and staff have been given appraisal forms for initial completion. Records seen confirmed this. Staff files have been revised and are in good order. Files contained two references as required at the last inspection. CRBs are available for all new staff in a separate file. Some CRBs have been applied for and are pending for long-standing staff. New Requirement: Birth certificates are required for all staff. Pat Shaw House Version 1.10 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 36, 38 The home is run in the best interests of service users. The home offers a good standard of care which is influenced by an positive management and leadership approach. 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 demonstrated a clear understanding of the health, safety and welfare of services users and staff. One person complained that her views were not listened to concerning exercise and food in the home, however the majority of 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 Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 1 COMPLAINTS AND PROTECTION 3 3 2 3 3 3 2 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 Standard No 16 17 18 Score 2 x x x 3 3 x x 3 x 3 Pat Shaw House Version 1.10 Page 20 yes Are there any outstanding requirements from the last inspection? 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. 2. Standard OP1 OP3 Regulation Schedule 1, 4(1) (c ) 14 Requirement The amended complaints procedure must be incorporated into the Statement of Purpose. The home must use one service user dependency form and staff must be trained on how to complete and implement the form. All needs identified in service user care plans must be signed by the service user or their family/representative (partly met). Service user risk assessments must be revised and expanded. All service users must be offered the choice to have their own keys and lockable cabinets in their rooms. The home must review its policies and procedures to ensure that service users’ right to privacy and confidentiality is respected at all times. Consultation with all service users (and or their family/representative) regarding their views on matters related to death, dying and funeral arrangements must be obtained Version 1.10 Timescale for action 1st Sept 05 1st Oct 05 3. OP7 5( c ) 1st Sept 05 (restated with new timescale) 1st Sept 05 1st July 05 4. 5. OP7 OP10 13 4(b) 12 6. OP10 12(3), 12 4(a) 1st July 05 7. OP11 12 (3) 1st Sept 05 (restated with new timescale) Pat Shaw House Page 21 in writing. 8. OP12 12, 15 The home must consult (and evidence consultation) with service users regarding their participating in physical exercise in the home. The home must provide or arrange for the provision of physical exercise for service users who wish to undertake such activities. The home must ensure the provision of wholesome, nutritious, fresh food and to ensure that processed foods are not the staple part of the menu. The complaints policy must be amended to specify that service users have the right to approach the CSCI directly. This amended policy must be given to all service users and the old policy, as seen in service user rooms, must be removed and discarded. . The lighting in the hallway downstairs must be improved A lampshade is still required in the first floor toilet. The Registered Manager to consult with staff regarding the manually assisted bath(s); to arrange for either training on the appropriate use of this equipment or, if applicable, to arrange for the assessment and provision of an alternative assisted bath in order to ensure the health and safety of staff. Water temperatures in the hand basins of some bedrooms were too hot and must be adjusted Version 1.10 1st July 05 9. OP15 16 2(i) 1st June 05 10. OP16 22 1st Sept 05 11. OP20 23(p) 12. OP21 23 13. OP22 23 1st Sept 05 (restated with new timescale) 1st Sept 05 (restated with new timescale) 1st Sept 05 14. OP25 23 23rd June 05 Page 22 Pat Shaw House close to 43 degrees. 15. OP25 23 The water pressure must be adjusted in the basin of the first floor toilet as the water spills over the basin flooding the floor when the tap is switched on. Birth certificates are required for all staff. 23rd June 05 16. OP29 19, Schedule 2 1 Sept 05 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 Good Practice Recommendations Pat Shaw House Version 1.10 Page 23 Commission for Social Care Inspection 4th Floor, 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 Version 1.10 Page 24 - 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!