Inspection on 10/10/05 for Peter Shore Court

This inspection was carried out on 10th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Peter Shore Court 19/05/08

Peter Shore Court 15/11/07

Peter Shore Court 26/04/06

Peter Shore Court 25/04/05

Peter Shore Court 30/10/04

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 Peter Shore Court Beaumont Square Stepney London E1 4NA Lead Inspector Nurcan Culleton Unannounced Inspection 10:30 10 and 13 October 2005 th th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Peter Shore Court DS0000052366.V259292.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. Peter Shore Court DS0000052366.V259292.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Peter Shore Court Address Beaumont Square Stepney London E1 4NA 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 790 2660 0207 790 7331 Excelcare Holdings Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Peter Shore Court DS0000052366.V259292.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th April 2005 Brief Description of the Service: Peter Shore Court is a purpose built residential home, managed by Excelcare Ltd, providing personal care and support for 41 older people. All service users have en suite rooms, there are 4 separate day/resource rooms located on the ground and first floors with an additional big lounge area on the ground floor for large functions. There is an additional quiet/smoking area. The premises consist of four separate units, located on the two floors. The home has lift facilities and aids and is suitable for people with disabilities. It is located within Stepney Green and is a short distance to Mile End, the Royal London Hospital and the City. The home is within walking distance of local shops, amenities and transport links. Peter Shore Court DS0000052366.V259292.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days on 10th October and 13th October. There were two inspectors conducting the inspection on the second day. The Manager and Regional Operations Manager were present on both days of the inspection. The inspection process was threefold, involving firstly, a detailed examination of documentation including service users’ assessments and files; inspection of staff files and other records relevant to National Minimum Standards. Secondly, random interviews took place with six staff members, four service users, one relative and the Activities Co-ordinator. Thirdly, the inspectors toured the premises and made observation notes. What the service does well: What has improved since the last inspection? What they could do better: The inspectors identified numerous concerns during this inspection, which has concluded that the home is operating below National Minimum Standards (NMS) in many areas. Whilst there is a desire to provide a good service and to raise standards in the home, this is not reflected in management strategies to deal with the areas of shortfall identified in this report. There are concerns regarding staffing levels, the effective use of staffing, the negative staff and management culture and the capacity of the home to meet individual service users’ needs. The quality of documentation related to service users is inadequate and there are serious concerns regarding medication practices. The increased risk to the health, safety and well being of service users is evident. There are 7 restated requirements, and 19 new requirements, a total of 26 requirements. The competency, support and training needs of the manager must be re-evaluated by the Provider. This service requires a competent and skilled manager, who has a clear idea of service users’ needs, with strong leadership skills and the ability to deal with the complexities described in this report. Peter Shore Court DS0000052366.V259292.R01.S.doc Version 5.0 Page 6 The CSCI received two complaints and reports of incidents from the home prior to the inspection prompting an additional visit by the Regulatory Manager (R.M) on 07/10/05 to check staffing levels and the safety of service users. The outcome of the visit raised similar concerns about staffing and questions about the safety of service users, which are expanded in this report. Timescales given for requirements may be subject to change following an Improvement Meeting due to take place between CSCI and the senior management of Excelcare. Excelcare must take urgent action to investigate and address the concerns highlighted in this report. 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. Peter Shore Court DS0000052366.V259292.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 Peter Shore Court DS0000052366.V259292.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 Prospective service users are provided with sufficient information in order to make an informed choice about the home. The practice and ability of the home to meet individual service users needs is variable and some service users needs are not being met when taking into account overall factors identified in this report. EVIDENCE: The Statement of Purpose and Service Users Guide contain sufficient information about the home, its services and facilities for prospective service users. Pre-admission assessments viewed in service users files are completed by the home following assessments by Social Services. However documentation examined by the inspectors related to service users, accounts given by staff and evidence seen by the inspectors showed that some service users’ needs are not being met in the home for a variety of reasons, given to and observed by the inspector, including staff resources, the culture within the home, in some cases the lack of understanding of service users’ needs by staff and managers and the lack of management strategies to deal with these difficulties to date (See Standard 7 and 27). Peter Shore Court DS0000052366.V259292.R01.S.doc Version 5.0 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, 11 Service users report being treated with respect. Improvements are still required to care plan and risk assessment documentation to ensure (1) all documentation is correctly completed and (2) where relevant, all assessed needs are cross-referenced in assessment tools to give an accurate picture of a service users’ care needs. Unsafe medication practises exist within the home. The home must maintain the privacy and dignity of service users. EVIDENCE: Service users spoken to said they liked the home and were treated with respect. Care plans are being completed for each service user using a format which identifies needs separately in a numbered system. The plans include actions identified to meet needs. A variety of Risk Assessments (R.A) forms follow from assessed needs, such as Waterlow Charts, Nutritional R. A, Moving and Handling R.A, Continence R.A and a general risk assessment. However there were several examples of inconsistencies, inaccuracies and some omissions in care plans and risk assessments regarding service users needs. Some examples included: a pressure sore had been recorded in the care plan, however this was not identified in the forms’ Nutritional Risk Assessment, where is it required to indicate a pressure sore need. Peter Shore Court DS0000052366.V259292.R01.S.doc Version 5.0 Page 10 A Waterlow Chart was missing for a service user with a pressure sore prevention plan. A form was completed for a diabetic noting that they had a medical condition not affecting food intake. The requirement to provide integrated care plans and risk assessments is restated. Individual care needs are not being reviewed regularly. Needs can frequently change and monthly review of care needs are appropriate to reflect changing needs. Records showed care needs last reviewed in June and July 2004 and no evidence of six monthly internal reviews. Annual statutory reviews are however being completed. The requirement for regular service user reviews is restated. The Manager in consultation with a District Nurse completed a Wound Progress Chart detailing specialist information related to service users needs. However there was no evidence of this consultation to validate the completion of the form which required specialist clinical knowledge. Specialist assessments must be completed by persons suitably trained to do so or evidence of consultation with the specialist professional must be provided. Excelcare must ensure that such documents containing clinical information and may be subject to changes are approved by a suitably trained health professional. Inspectors observed a gap in health care notes from 11/09/05 from a District Nurse who regularly treats a service user with a pressure sore. Several requirements are given concerning medication. These follow the following observations during a tour of the premises: Hydrocortisone (prescribed steroid) and Daktarin creams left openly on top of the toilets in two service users’ rooms, with potential risk to confused and vulnerable persons. An Ibuprofen cream also left exposed in bathroom. This cream expired in July 2004. The label on one Daktarin cream had faded off with no name on the tube inside. The label on another cream had been tampered with without verification of the person’s authority to alter the label. There were 4 gaps in one Medication Administration Record (MAR) providing no information about whether or not medication was administered as prescribed. The requirement to ensure accurate MAR sheets is restated. The inspectors viewed incontinence pads stored openly in service users rooms. This is contrary to maintaining the privacy and dignity of service users and the maintenance of a homely environment as promoted in National Minimum Standards. The home still has no ‘death and dying’ policy related to whether service users are able to spend their final days in their residential home and in their rooms. The inspectors were informed that all policies are being reviewed with the Provider Relationship Manager at CSCI. Also death and dying wishes were generalised to each service user and did not specify the wishes of the individual service user, which must be sought out Peter Shore Court DS0000052366.V259292.R01.S.doc Version 5.0 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 The home provides limited social and leisure activities for its service users and must provide more opportunities for stimulation. Service users have a choice of food which is balanced and nutritious. Service users meetings must be reinstated. EVIDENCE: The Activities Co-ordinator was present during the inspection. The Co-ordinator informed she works four days a week and staff provide assist with activities on the other days. However staff report that their caring duties are time consuming. The Co-ordinator has received no training in her role, for example, for reminiscence activities. Church ministers provide a service in the home on Sundays. Activities remain fairly limited and service users must be given further opportunities for stimulation both inside and outside of the home. Service users report that they maintain contact with family and friends and the inspectors spoke with one service users’ daughter who was visiting the home. Service users have a variety of nutritious food and are consulted about their preferences on a regular basis. The last noted relatives meeting took place in July 2005. The last service users meeting was recorded in March 2004. Service users’ meetings must be encouraged and facilitated. Peter Shore Court DS0000052366.V259292.R01.S.doc Version 5.0 Page 12 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, 18 The Manager must improve their practice and culture of dealing with service users’ complaints and to ensure the home follows and maintains a robust complaints procedure. EVIDENCE: The CSCI have received several complaints from service users relatives and staff respectively since the last inspection in April 2005. The Manager and Regional Operations Manager are investigating the latest complaints and will report to CSCI. A service user informed the inspectors that recently two of her personal ornamentations had been missing, and in her view were stolen. She had reported this to staff. Minutes of a staff team meeting viewed by the inspectors also showed that money had gone missing from the same service user three months ago. The Manager was aware that the ornaments had gone missing and that staff were checking her room, however this was not treated as a complaint and was not entered into the complaints book, nor was the missing money recorded or evidently investigated. The home has a satisfactory complaints policy, however only one complaint had been recorded in the book since the last inspection of April 2005. This complaint was made by a social worker on behalf of the daughter of a service user in the home. It was also made to the CSCI and investigated by the home. A family member spoken to during the inspection informed that she was unhappy with the homes’ approach to complaints as she herself had cause to complain on several occasions and was not satisfied that her complaints had been dealt with. The home was unable to evidence the outcome of complaints with any family members. Peter Shore Court DS0000052366.V259292.R01.S.doc Version 5.0 Page 13 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 generally well maintained, clean and tidy. The upstairs lounge must be free from odour. Wheelchairs must be safe when used to mobilise service users. EVIDENCE: The inspectors observed the home to be generally in good order and homely in its décor. Bedrooms were furnished with personal possessions and rooms were generally clean, tidy and suitable for service users’ needs. Rooms were free of odour with the exception of the lounge on the first floor, which had a strong, smell of urine. This must be attended to. The wall in the ground floor hallway requires repair and decoration following chipped paintwork. There are aids and adaptations, including wheelchairs, hoists and lifts suitable for disabled persons. The daughter of the service user spoken to during the inspection complained that the foot rests on the wheelchairs were often not in correct position and left at the sides by carers, posing a risk to the feet of service users when moving around. One service user’s wheelchair seen by the inspectors had no footrest. The service user informed they were missing. Peter Shore Court DS0000052366.V259292.R01.S.doc Version 5.0 Page 14 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 The home is unable to evidence that it has sufficient staff resources and skills to meet service users needs. Staff have received some training though support and training needs must be further identified and met. EVIDENCE: Staff morale is generally low and sickness levels are high. The CSCI has received several complaints from staff and service users relatives concerning insufficient staff numbers at Peter Shore Court (PSC) and the detrimental impact on service users. The inspectors have attempted to examine whether staff numbers are sufficient to meet service users needs. The inspectors uncovered a number of issues concerning staffing levels at PCT. Firstly, there were differences in understanding between the Manager and staff about the level of needs of some service users. The Manager informed that none of the service users needs had high level needs in terms of requiring two staff members or requiring a high level of one to one staff time. The inspector spoke with six staff members. Staff gave the inspector examples of three service users who frequently required two staff members to assist them for reasons of their behaviour or their need to use a hoist. The inspectors also directly observed a frail elderly women on her bed with high level needs requiring a hoist and two persons to transfer her safely. There was a lack of acknowledgement from the Manager that this service user had high level needs. Peter Shore Court DS0000052366.V259292.R01.S.doc Version 5.0 Page 15 Secondly, the Manager informed that there was generally one staff member to seven service users on duty at most times. On the first day of inspection there were five staff members on duty to care for thirty three service users. Staff informed the inspector that there was one staff member caring for twelve service users on the first floor unit. The senior care assistant responsible for the rota also confirmed this. On this day, whilst there were five staff members on the rota, three of these staff members were caring for more dependent service users downstairs. This left one staff member on the first floor unit for five service users and the other staff member caring for twelve service users described by staff as ‘less dependent’. This level of staffing is unacceptable and unsafe. Furthermore, the Manager appeared unaware when informed that there was one staff member caring for twelve service users upstairs. Staff confirmed that this frequently happened, that it was difficult to respond to service users’ needs, for example to assist with toileting, and that they would call on the Senior Care Assistant to assist. The Manager and staff informed the inspector that there is normally a ‘floater’ between the two first floor units in the morning. Staff informed there is no floater in the afternoon. Thirdly, there is the lack of clarity about the duties of the Senior Care Assistant, who is responsible for medication and senior duties in addition to providing care support. The Manager informed that the Senior Care Assistant must perform care tasks. The Senior interviewed described the difficulties of providing care assistant support. In practise, one staff member to twelve service users with occasional assistance from the Senior Care Assistant is insufficient to meet service users needs. Fourthly, there are concerns about the negative culture within which the home operates. There are perceptible tensions evident between the management and staff with staff exhibiting a deep distrust of the current provider and distrust and a lack of respect for the Manager: (1) The Manager and Regional Operations Manager report alleged manipulation by care staff ( particularly those that transferred from the previous owner) of the roster through sickness and annual leave i.e dictating their shift patterns. have reported that there are difficulties among some staff members who are not willing to work together with the management team. For example, staff unwilling to be flexible on the staff rota, has created difficulties in finding replacement staff on some occasions. The Manager informed that despite this difficulty, bank staff are regularly found and used without difficulty on most occasions. Contrary to the above, staff reported that there are regular difficulties in finding bank staff and staff end up working long hours. This they say causes them low morale and increases their sickness levels. In addition, there is an issue of staff not being paid their regular or for additional hours worked without staff chasing up their claims, leading DS0000052366.V259292.R01.S.doc Version 5.0 Page 16 (2) Peter Shore Court to a worst state of morale among staff and a feeling of being devalued. Some staff reported denial of annual leave requests. Inspectors observed restrictions on annual leave as discussed in minutes of team meetings. Staff concluded that they felt badly treated by their manager and the wider management of Excelcare. The above can be summarised as follows: There is a difference in perception of service users’ needs between the Manager and staff. There is an apparent lack of understanding by the Manager of the high level of needs of some of the service users. Evidence of the needs of service users with high level needs being unmet Insufficient levels of and deployment of staffing to meet service users’ needs. Lack of clarity of the role of the Senior Care Assistant Deep distrust of the current Provider by care staff; Distrust and lack of respect for the Manager; Low staff morale; High sickness levels; A culture of negativity amongst staff; Poor communication between the manager and staff; Alleged manipulation by care staff (particularly those that transferred from the previous owner under TUPE arrangements) of the roster through sickness and annual leave i.e. dictating their shift patterns; Peter Shore Court DS0000052366.V259292.R01.S.doc Version 5.0 Page 17 Following interviews with the Manager, staff, service users and examination of random service user files, the home is unable to demonstrate that it is able to meet the needs of at least three service users, two of whom are doubly incontinent and use hoists for transfers, at least one of whom requires two members of staff for safe transfers and two service users who are very confused. Staff files were mostly in order, with three exceptions: All staff members must have up to date CRBs. Photographs of staff must be available in their files. Old job descriptions quoting nursing care responsibilities for care staff must be removed from staff files. The inspectors viewed thirteen CRBS available in the home, roughly belonging to half the staff members. The Regional Operations Manager (ROM) informed that the other staff members had CRBs from their employment in Springboard, the former provider of the establishment. The ROM advised that they were in the process of obtaining the remaining CRBs and all staff had received application forms. Staff confirmed they had training and most staff have an NVQ Level 2 award. Some staff expressed a need for more support and training. Training records were patchy and difficult to interpret. Moving and Handling training is required for the completion of these assessments. This includes the need for Moving and Handling training for the Manager. The home has begun the process of compiling a Personal Development File for each staff member. The inspectors were informed these would incorporate individual training records. Peter Shore Court DS0000052366.V259292.R01.S.doc Version 5.0 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 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 The management of the home currently falls short of delivering the homes’ aims and objectives as well as National Minimum Standards. Service users are disadvantaged by the leadership and management approach in the home. The home cannot evidence that the health, safety and welfare of service users are promoted and protected. Staff supervision has been inadequate. Service users gave positive feedback about the home and staff in quality assurance questionnaires. EVIDENCE: The Manager has a background in social care and is undergoing NVQ Level 3 training. National Minimum Standards state that the Manager must achieve NVQ Level 4 in management and care by 2005. Staff spoken to at random have a negative perception of the support they receive from the Manager. In lieu of feedback gained from staff in supervision or regular attendance at staff handover meetings, the Manager relies heavily on the information given to her Peter Shore Court DS0000052366.V259292.R01.S.doc Version 5.0 Page 19 by the Senior Care Assistant in respect of service users’ needs. The Manager must act as a role model on the ground and create an open and positive management approach in the home. They must further demonstrate that they have adequate knowledge, skills and experience to manage and lead an establishment such as Peter Shore Court. This means having an understanding of the needs and best interests of its service users, the support and development needs of its staff and the ability to provide leadership and direction to meet the homes’ stated aims and National Minimum Standards. Tensions are perceptible between the Manager and staff and reported to the inspectors. The staff gave accounts of the Manager being too busy to respond to their needs when approaching the Manager for advice or assistance. The Manager gave her view that some enquiries by staff were more appropriate to be dealt with by the team leader or senior care assistant or she would explain to staff that she would get back to them at a more convenient time if busy. The result of this tension is the impact on staff performance and on service delivery. Further investigation is required by the Provider to identify and address whether these difficulties are as a result of the lack of sufficient seniors or team leaders within the management structure to provide adequate support, the lack of adequate training for staff or the management approach within the home. A sample of service users’ personal allowances was checked and deemed to be correct at the time of inspection. Until September 2005, staff had not received supervision for approximately one year. Supervision targets have failed since the last inspection and may have contributed to poor practice and lack of staff development within the home. Supervision sessions now appear to be in place. Quality assurance surveys from service users evidence that service users are satisfied with staff and the home. Positive comments were noted. Quality monitoring systems into care planning and recording practices and the quality of service provision against National Minimum Standards must be improved to provide the safeguard needed for this establishment. Staff spoken to were unaware of who was trained in first aid on their shift. The staff rota could not evidence that a staff member trained in first aid was on the rota for each shift. Not all staff who had completed moving and handling assessments had received training in moving and handling. The home must make arrangements to provide a safe system of moving and handling, ensuring that only those staff who have sufficient knowledge and understanding of moving and handling issues complete moving and handling assessments. Peter Shore Court DS0000052366.V259292.R01.S.doc Version 5.0 Page 20 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 3 x 3 x 3 x 3 1 3 1 3 3 3 1 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 1 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 1 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 x 18 3 STAFFING Standard No Score 27 1 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 1 x 3 1 1 1 Peter Shore Court DS0000052366.V259292.R01.S.doc Version 5.0 Page 21 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 Timescale for action 31/12/05 2. OP7 15 3 OP7 15 4 OP7 14(1), (2) The Manager must ensure that all care plans and assessment documentation must contain accurate information and they are adequately completed. All care plans must include needs 31/12/05 and actions identified in risk assessments (Timescales of 15th March 2005 and 10th August 2005 are not met). The Manager must ensure that 31/12/05 where relevant, all assessed needs are cross-referenced in all assessment tools to give an accurate picture of a service users’ care needs. The Manager must ensure that 31/12/05 assessed needs in care plans are reviewed on a regular (monthly) basis. (Timescale of 10th August 2005 not met). Peter Shore Court DS0000052366.V259292.R01.S.doc Version 5.0 Page 22 5 OP7 14(a) The Provider must ensure that: a) specialist assessments such as the Wound Progress Chart are clinically approved and are documents in current usage. b) Such assessments must be completed by suitably trained persons and their identity disclosed. c) Alternatively, consultation with the trained specialist must be evidenced. 31/12/05 6 OP8 13, Schedule 3 13 (2) 13(2) 7 8 OP9 OP9 9 10 OP9 OP9 13(2) 13(2) 11 OP10 12(4)(a) The Manager must ensure that notes related to health care needs of service users are maintained and updated by health care professionals. All prescribed medication must be stored appropriately in lockable cabinets. The Manager must ensure there are no gaps in the Medication Administration Records (MAR). (Timescale of 10th August 2005 not met) The Manager must make arrangements for the safe disposal of expired medicines. All medication must be clearly labelled and any alteration to the label must be authorised by the pharmacist. Incontinence Pads must be appropriately stored in order to maintain the privacy and dignity of service users. 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 Peter Shore Court DS0000052366.V259292.R01.S.doc Version 5.0 Page 23 12 OP11 12(1) 13 OP12 16(2)m 14 15 OP12 OP16 12 22 The home must ensure it has (1) 31/12/05 a ‘death and dying’ policy on whether service users are able to spend their final days in the home and (2) a personalised statement, not a generalised one, of service users’ death and dying wishes. (Timescales of 31 Jan 2005 and 10th Aug 2005 not met) 31/12/05 Service users must be given further opportunities for stimulation both through social, leisure and activities of cultural interest both inside and outside of the home. (Timescale of 10th Aug 2005 not met) Service users’ meetings must be 31/12/05 encouraged and facilitated. The Manager must improve their practice of dealing with service users’ complaints and to ensure the home follows and maintains a robust complaints procedure. The wall in the ground floor hallway requires repair and decoration following chipped paintwork. The Manager must ensure that foot rests are in correct position at all times when staff move service users around in wheelchairs. The Manager must evidence to the Commission that it has adequate levels of staffing to meet all its service users needs and to ensure that service users’ needs are met at all times. 31/12/05 16. OP20 16 31/12/05 17 OP22 13(4) 31/12/05 18 OP27 18(1)(a), 12 31/12/05 Peter Shore Court DS0000052366.V259292.R01.S.doc Version 5.0 Page 24 19 OP29 Schedule 2, 19 20 21 OP30 OP31 18 9, 18, 19 22 OP32 12(5)(a) The Manager must ensure that (1) All staff have current enhanced CRB checks. (2) Old job descriptions quoting nursing care responsibilities for care staff must be removed from staff files and (3) Each member of staff has a photograph identification in their file. The Manager must ensure and evidence that staff training needs are identified and met. The Provider must ensure that the Manager has a clear understanding of individual service users’ needs. The Provider must: (a) address staff’s negative perception of the management approach to their support needs within the home. (b) must take appropriate measures to improve communication and working practises between care staff and the management team. The Provider must ensure that there is improved qualityassurance monitoring to ensure that the service meets National Minimum Standards. The Manager must ensure that staff receive supervision at least six times a year, an annual appraisal and must keep a record of all training and development activities. The Manager must ensure that persons with sufficient training and understanding to do so complete Moving and Handling assessments. 31/12/05 31/12/05 31/12/05 31/12/05 23 OP33 24(1), 26 31/12/05 24 OP36 18(2) 31/12/05 25 OP38 13(3)(5) 31/12/05 Peter Shore Court DS0000052366.V259292.R01.S.doc Version 5.0 Page 25 26 OP38 13(4)(c) The Manager must ensure that there is a member of staff trained in first aid is on each shift. All staff members on that shift must be aware of the identity of the staff member trained in first aid on their shift. 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Peter Shore Court DS0000052366.V259292.R01.S.doc Version 5.0 Page 26 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 Peter Shore Court DS0000052366.V259292.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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