Inspection on 24/05/06 for Pat Shaw House

This inspection was carried out on 24th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 12/12/05

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 Key Unannounced Inspection 24th May 2006 10:00 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.V295322.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. Pat Shaw House DS0000052367.V295322.R01.S.doc Version 5.2 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.V295322.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 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 has 32 bedrooms with toilets and hand-basins and 6 en-suite bedroom flats located on three floors, the ground and two floors above. All rooms are spacious, clean and are wheelchair accessible. There are specialist facilities to assist disabled service users. There are communal rooms for service users use on each floor. There is also a small garden with a patio. 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. Pat Shaw House DS0000052367.V295322.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 on 24th May 2006. The Registered Manager assisted the inspector throughout. The inspector consulted with 3 members of staff, 3 individual service users and 2 groups of service users during the inspection to seek their views about the home. The inspector also examined the home’s written documentation, including service users’ assessments and care plans and toured the home. 33 service users were residing in the home at the time of inspection. 2 service users were in hospital and there were 2 vacancies. In addition to a range of standards inspected, the inspector reviewed 3 requirements and 5 recommendations made at the last inspection. What the service does well: What has improved since the last inspection? What they could do better: One requirement has been given concerning the need to improve daily records in service users’ files to ensure that care and support given is explicitly recorded. Pat Shaw House DS0000052367.V295322.R01.S.doc Version 5.2 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.V295322.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 Pat Shaw House DS0000052367.V295322.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Service users can be confident that a process of assessment takes places to determine whether the home can meet their needs prior to admission in the home. Standards 1, and 4 were assessed and met at the last inspection. There is no intermediate care provision. EVIDENCE: The inspector viewed the files of two new service users admitted since December 2005. Pre-admission assessments and a dependency tool assessment completed by the Registered Manager and Team Leader were seen in the files. Consultation with multi-disciplinary health and social services professionals, service users and their families was evident. Service users confirmed that they have frequent visits from their families and trips out with them. Pat Shaw House DS0000052367.V295322.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Service users’ health, personal and social care needs are clearly outlined in their individual care plans. Service users’ ongoing health needs are being met. Service users’ privacy and dignity is respected. A recommendation is given concerning care staff completing specialist assessments. EVIDENCE: The inspector viewed four service user care plans. These comprehensively outlined service users’ needs. Each need is specified on a separate page and the goals and actions required are identified. Each need was reviewed on a monthly basis, irrespective of whether needs had changed. The inspector observed a continence assessment form in the files which uses language understood only by those who have specialist knowledge and training. The Registered Manager acknowledged that both she and her staff were uncomfortable using such forms without sufficient understanding of the terminology and their lack of training to complete them. The issue of care staff completing such specialist forms is currently under discussion between Pat Shaw House DS0000052367.V295322.R01.S.doc Version 5.2 Page 10 Excelcare and CSCI. However a recommendation is made against their usage by untrained staff in the interim. Regular contact with health professionals was evident in records seen. Service users attend medical appointments as may be necessary. In addition, Regulation 26 notices are received by CSCI informing when appropriate urgent medical attention is sought. Medication records were checked against medicines administered and deemed to be correct at the time of the inspection. A requirement to store incontinence pads discreetly to preserve the privacy and dignity of service users was met. The Registered Manager had consulted with all service users about this and action was taken to address the issue. In addition, service users’ spoken to said that all staff treated them well and with respect. Service users were on the whole complimentary about the support they received from staff. A couple of service users said that some staff were not always courteous (for example, omitting to say good mornings and goodbye) but said that the majority of staff were always polite. Pat Shaw House DS0000052367.V295322.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. 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: Excelcare have recently appointed a manager with overall responsibility to supervise the activities co-ordinators. Service users benefit from a range of activities in the home, which they informed that they were pleased with. Activities were displayed on the service users’ notice boards, including bingo, exercises, and painting. In addition, outside visitors come to the home, such as a community school which visits three times monthly. Some service users’ confirmed that they were independent and free to make their own visits to places of their choice outside the home. One service user spoken to informed that she was still able to go to the shops alone. Others go to the shops with staff. Some visit friends and church and others attended day centres. A Pastor attends the home every Sunday. Another service user showed the inspector specialist items of food she likes to buy from the shops to improve her health. She also eats Kosher meals. The Registered Manager said there were no service users who had other special religious or cultural needs but said that the Pat Shaw House DS0000052367.V295322.R01.S.doc Version 5.2 Page 12 home was able to cater for special needs as required. Service users are consulted about their food preferences and the menu is wholesome and nutritious. Most service users said the food was good and some said the food was variable. Inventories of personnal possessions have now been completed or are underway in consultation with service users. Pat Shaw House DS0000052367.V295322.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The home has a positive approach to complaints. Service users and their relatives’ can be confident that their views are listened to, taken seriously and acted upon and that issues raised with management are promptly addressed. EVIDENCE: There were 2 recorded complaints from service users since the last inspection. These were appropriately investigated and the service users’ complaints were promptly addressed. Service users are all registered and enabled to vote. Staff receive relevant training and supervision regarding protecting vulnerable adults from abuse and an appropriate policy and procedure is in place. Pat Shaw House DS0000052367.V295322.R01.S.doc Version 5.2 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. 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, raised beds and chairs, commodes and wheelchairs. Service users’ specialist needs are assessed by an occupational therapist. Service users’ rooms are personalised with furnishings, such as items including a bed, chest of drawers, pictures, televisions and other possessions. A requirement at the last inspection to improve the lighting in the hallway had been met. Two previous recommendations were met. Alternative space to store wheelchairs has been explored by the Registered Manager since the last inspection. Service users have been consulted about the colour of their rooms and some rooms have been repainted to suit individual tastes. Pat Shaw House DS0000052367.V295322.R01.S.doc Version 5.2 Page 15 Pat Shaw House DS0000052367.V295322.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. There are sufficient numbers of skilled staff to meet service users’ needs. Staff files are in good order, evidencing good recruitment practices and good maintenance of staff records. Staff receive 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 always available to meet their needs. Staff informed that there was a good team spirit and they had a good supportive relationship with the manager. There are presently 23 permanent care staff employed and 6 seniors. 6 bank staff are used to cover staff shortages. There are wake-in staff members at night. The seniors supervise the care staff and the manager supervises the seniors. There are also cooks, cook assistants, a kitchen assistant, handyman, cleaners and a 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.V295322.R01.S.doc Version 5.2 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): 31, 32, 33, 35, 36, 37, 38 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. 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. A requirement is given concerning the need to improve daily records in service users’ files. EVIDENCE: The Registered Manager has an RMA award, 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 worked as a senior carer in the home for 7 years prior to managing the home. Pat Shaw House DS0000052367.V295322.R01.S.doc Version 5.2 Page 18 She has also had previous experience of managing a care home for people with mental health problems. Service users on the whole praised the staff and management of the home. The inspector observed a good relationship among service users and staff. The Registered Manager shows a positive ethos, leadership and management to the running of the home. The Registered Manager has in place systems and procedures, such as daily tours around the home to ensure open lines of communication with staff and service users and familiarisation with service users’ nees and spot checks to ensure that all staff perform to their expected standards of service. The Registered Manager was able to demonstrate an intimate knowledge and clear understanding of the welfare needs of services users and staff as a result. Ongoing quality assurance surveys, relatives and residents meetings ensures that the home is responsive in meeting service users’ needs. Staff expressed satisfaction with the Registered Manager, informing that she was supportive, helpful and very efficient. All staff receive regular, recorded supervision sessions. A sample of four service users’ personal allowances were checked. All examined accounts were correct at the time of inspection. A requirement is given to improve record keeping in service users’ files. Daily accounts in service users notes must explicitly state what type of care and support is given to service users. Records of care and support given to service users must be tied in with service users’ identified needs as recorded in their care plans. Records were not explicit enough, ie, in one persons’ file,’ personal care given’, was recorded and apparently contradictory recording was noted in the same persons’ file recording, ie self-caring, noted on another day etc. The home must ensure that all care and support given to service users is clearly and explicitly recorded. All health and safety certificates requested were available for inspection. Pat Shaw House DS0000052367.V295322.R01.S.doc Version 5.2 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 x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 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 x 3 3 2 3 Pat Shaw House DS0000052367.V295322.R01.S.doc Version 5.2 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 OP37 Regulation 17 Requirement All daily records of care and support given to service users must be clear and made explicit and must tie in with needs identified in service users’ care plans. Timescale for action 10/10/06 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 OP3 Good Practice Recommendations However a recommendation is made that only trained and knowledgeable staff complete assessment forms requiring specialist knowledge and training. Pat Shaw House DS0000052367.V295322.R01.S.doc Version 5.2 Page 21 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.V295322.R01.S.doc Version 5.2 Page 22 - 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. 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