Inspection on 26/04/06 for Peter Shore Court

This inspection was carried out on 26th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 10/10/05

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 26th and 27th April 2006 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.V290442.R02.S.doc Version 5.1 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.V290442.R02.S.doc Version 5.1 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 *** Post Vacant *** Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Peter Shore Court DS0000052366.V290442.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th October 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.V290442.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days on 26th and 27th April 2006. The Manager assisted the inspector on both days. The Head of Care was also present during the inspection. The inspection process was threefold, involving firstly, a detailed examination of documentation including four service users’ assessments and files; inspection of four staff files and other records relevant to National Minimum Standards. Secondly, random interviews took place with four staff members, five service users and two relatives. Thirdly, the inspector toured the premises and made observation notes. What the service does well: What has improved since the last inspection? What they could do better: Two restated requirements are given regarding the recording of administration of medicines and the safe disposal of expired medicines. Peter Shore Court DS0000052366.V290442.R02.S.doc Version 5.1 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. Peter Shore Court DS0000052366.V290442.R02.S.doc Version 5.1 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.V290442.R02.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The ability of the home to meet individual service users’ needs has improved. Service users needs are now being met. Service users are benefiting from comprehensive assessments of their needs. EVIDENCE: The Statement of Purpose and Service Users Guide have been recently updated and contain sufficient information about the home, its services and facilities for prospective service users. Two types assessments were viewed in service users files, one initial assessment and a dependency level assessment, which are completed by the manager prior to a new admission. The assessments comprehensively outlined service users’ needs. The inspector examined further documentation in service users’ files and received first hand accounts by service users and staff to satisfied the inspector that service users’ needs are now being met in the home. Intermediate care is not provided in the home. Peter Shore Court DS0000052366.V290442.R02.S.doc Version 5.1 Page 9 Peter Shore Court DS0000052366.V290442.R02.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Significant improvements have been made to care plan and risk assessment documentation to ensure that service users’ assessed needs are clearly set out and met. Service users treated with respect. Restated requirements are given regarding the recording of the administration of medication and the safe disposal of expired medicines. EVIDENCE: Service users and relatives spoke very highly of the care they received from staff, who they described as kind, caring and describing them as kind, caring, friendly and responsive to their needs. They liked the home and thought that they were treated with dignity and respect. This view was shared by the relatives spoken to. There has been significant team work and effort, including from the management team to carers, into improving the quality of the care plans. A care plan matrix, devised a month ago, is now in each service users’ file, detailing all the documents required for each service users’ file. A timetable, Peter Shore Court DS0000052366.V290442.R02.S.doc Version 5.1 Page 11 continuing over the coming months, has been devised to ensure that all carers review and update service user’ care plans; that seniors check the quality of the care plans by care staff and that the manager undertakes weekly audits of 5 care plans to ensure the quality of work conducted by seniors is maintained. All care staff have received training regarding care plans. The improvements were evident in files examined. All care plans inspected had been updated for each service user. The care plans clearly identify service users needs separately in a numbered system. The plans also clearly include actions required to meet identified needs. A variety of Risk Assessment (R.A) forms follow from assessed needs, such as, Nutritional R. A, Moving and Handling R.A, Continence R.A and a general risk assessment. The inconsistencies, inaccuracies and omissions in care plans and risk assessments regarding service users needs, which were identified at the last inspection and were a cause for concern, have been addressed for this inspection. The requirement to provide integrated care plans and risk assessments has been adequately achieved to meet the standard. All assessed needs are cross-referenced in assessment tools to give an accurate picture of a service users’ care needs. Statutory reviews have been undertaken and are being arranged for all service users where required. The inspector also observed that all health care notes are now up to date and that forms requiring specialist knowledge of assessments and procedures such as moving and handling, are only completed by staff, currently senior carers, who have received relevant training. Several requirements were given at the last inspection concerning unsafe medication practises and inaccurate recording of the administration of medicines. Medication practises have generally improved. Senior carers have primary responsibility for the administration of medicines and their medication training is ongoing by Britannia Pharmacy. Ten carers are also enrolled to take medication training. The new trainee manager, who is a trained nurse, and the Head of Care have been undertaking weekly and monthly audits regarding medication practises. However, the inspector observed an error on one service users’ MAR sheet where a signature had been given from a carer to indicate that medication had been administered that evening and for the following day when this was clearly not possible. In addition, the inspector observed a box of eye drops for one service user which showed that the date had expired and should have been returned to the pharmacy four weeks earlier. Restated requirements are given to ensure the accurate recording of administration of medicines and to ensure the safe disposal of expired medicines. Peter Shore Court DS0000052366.V290442.R02.S.doc Version 5.1 Page 12 The home still had no ‘death and dying’ policy related to whether service users are able to spend their final days in their residential home. However the Manager was able to rectify this by including a policy statement about this in the Statement of Purpose during the inspection. In addition individual signed death/dying/wishes were seen in service user’s and consultation regarding this issue was evident. Peter Shore Court DS0000052366.V290442.R02.S.doc Version 5.1 Page 13 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 adequate. This judgement has been made using available evidence including a visit to the service. The home has improved its social and leisure activities for its service users and provides more opportunities for stimulation. This work is still developing. Service users have a choice of balanced and nutritious food. Service users maintain contact with family and friends. EVIDENCE: Since the last inspection, further social opportunities have been introduced to the home. A display in the reception area shows details of monthly entertainments brought in from a variety of outside entertainers. Service users commented how much they enjoyed these. The organisation has now appointed an Activities Co-ordinator Manager who will supervise all Activities Co-ordinators. One service user attends a day centre on a daily basis, however she expressed that she would like more varied visits outside. The inspector was satisfied that individual and group activities are undergoing improvement and review and that improvements have already been made. This will be reviewed at the next inspection. Peter Shore Court DS0000052366.V290442.R02.S.doc Version 5.1 Page 14 Service users report that they maintain contact with family and friends and the inspectors spoke with two service users’ daughters respectively who were visiting the home. The relatives informed that the home was excellent and that were very happy for their relatives in the home. Service users have a variety of nutritious food including fresh fruit and vegetables. Service users are offered a choice of food a day in advance and are consulted about their preferences for the menu on a monthly basis. Service users accounts of their enjoyment of the food were variable however evidence of consultation regarding food was examined. Residents meetings have been reinstated and relatives meetings are have also taken place. Peter Shore Court DS0000052366.V290442.R02.S.doc Version 5.1 Page 15 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 judgement has been made using available evidence including a visit to the service. The home has developed a positive attitude and significantly improved its approach to dealing with complaints. Service users and their relatives are confident that their concerns or complaints are dealt with promptly and thoroughly. EVIDENCE: The CSCI received one major complaint from an ex member of staff concerning poor care practises in the home prior to the new management in the home. The inspector is satisfied that similar concerns had been identified at the last inspection and that the home has since made significant improvements to address the requirements made to address these shortfalls. The Manager informed that no complaints had been brought to her attention since her employment. This was reflected in the views expressed by carers, service users and relatives alike. All stated that any issues raised with the Manager are promptly addressed before they develop into complaints. Service users are registered to vote. Staff are undergoing a programme of training including Adult Protection. Staff spoken to showed that they were aware of Adult Protection issues and procedure. Peter Shore Court DS0000052366.V290442.R02.S.doc Version 5.1 Page 16 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is generally pleasant, comfortable, and well maintained. The space available for use as a garden at the back of the home could be developed to improve the quality of life experienced by service users in the home. EVIDENCE: The inspector toured the premises and observed the home to be generally in good order and homely in its décor. It was clean, tidy and free from odours. Bedrooms were furnished with personal possessions and rooms were generally clean, tidy and suitable for service users’ needs. Rooms were free of odour. The wall in the ground floor hallway had been repaired and redecorated as required. There are aids and adaptations, including wheelchairs, hoists and lifts suitable for disabled persons. Foot rests on wheelchairs are now held in pins so as not to be removed, addressing a previous requirement and complaint made by a relative at the last inspection. Service users and relatives expressed that Peter Shore Court DS0000052366.V290442.R02.S.doc Version 5.1 Page 17 they were very satisfied with the environment and thought the home was very pleasant. The inspector noted however that there is no garden in the home. This could present a disadvantage to service users who may wish to enjoy a garden, particularly for people who may have restricted choices in their activities or their environment. There is however some space at the back of the home with potential to be developed into a garden. The Manager informed that garden furniture has been bought. The inspector recommends the further development of an appropriate garden space at the back of the home. Peter Shore Court DS0000052366.V290442.R02.S.doc Version 5.1 Page 18 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 judgement has been made using available evidence including a visit to the service. The home is able to evidence that it has sufficient staff resources and skills to meet service users needs. Measures are now in place to assure service users of their improved safety, care and support which they receive from staff. EVIDENCE: At the last inspection, there were several areas of concern related to staffing which have been addressed and are continuing to be developed. In contrast with the previous inspection, there has been a major shift in the improvement of staff morale and sickness levels are now low. The positive impact on service users is evident in service users’ and their relatives’ accounts of an improved service and warmth and sensitivity shown by the carers. The inspector was satisfied that there were sufficient staff numbers to meet service users needs. There are presently 32 service users to 15 carers and 5 seniors. There equates approximately to 1 staff member to assist 7 service users, which, according to interviews during the inspection, the needs of the service users and training received by the carers, is sufficient. An ongoing programme of staff training is underway and the inspector was shown a Training Matrix for staff outlining training received by staff, which is in Peter Shore Court DS0000052366.V290442.R02.S.doc Version 5.1 Page 19 the process of being updated. Yearly training needs are also forecast for each staff member. Staff files inspected contained all required documentation and are in order. Peter Shore Court DS0000052366.V290442.R02.S.doc Version 5.1 Page 20 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 excellent. This judgement has been made using available evidence including a visit to the service. The manager of the home has demonstrated their ability to deliver the homes’ aims and objectives. Service users now benefit from having strong leadership and management. The home can evidence that the health, safety and welfare of service users are promoted and protected. EVIDENCE: The Manager has a background of working in the provision of care for the elderly for 18 years prior to joining Excelcare as a manager 3 years ago. She has gained the D32-33 Assessors award, an NVQ3 and is working towards the NVQ Level 4/RMA award. Staff spoken to at random reported that the Manager has had a very positive effect on the home and that they now feel supported. Peter Shore Court DS0000052366.V290442.R02.S.doc Version 5.1 Page 21 The Manager has successfully created an open and positive management approach in the home. She was able to demonstrate that she is equipped with the necessary skills and experience to manage, lead and meet the challenges initially presented to her at Peter Shore Court. The Manager showed good knowledge and understanding of the individual support needs of the service users and of the support and development needs of staff. There was also acknowledgement that whilst significant improvements have been made, this is still work in progress. However, thus far, there has been a positive impact on staff performance and on service delivery. To assist with the improvement agenda of the home, a temporary trainee manager has been employed to assist the Manager in work such as reviewing the quality of care plans and medication records. An improved system of supervision is in place. All seniors have now been delegated the task of supervising care staff on the units which they have responsibility for. This ensures that all staff receive adequate, ongoing supervision and support. The seniors are supervised by the Manager. Staff spoken to informed the inspector that there is a much improved atmosphere in the home and that they feel that their support needs are now being met. They feel that the Manager is approachable and understanding. Quality assurance monitoring across all areas of service provision has improved. The senior managers at Excelcare have had weekly consultations with the Manager to ensure that the home effectively delivers its action plan. External consultants and audits from the London Borough of Tower Hamlets have also contributed in this process. The home has improved systems to operate more effectively. Results seen from service users’ and their relatives’ quality assurance surveys evidence that service users are satisfied with their service, the staff and the home. Positive comments were noted. The Manager advised that all seniors were trained in first aid and some are awaiting certificates. A sample of service users’ personal allowances was checked and deemed to be correct at the time of inspection. All relevant health and safety check certificates were available and current at the time of inspection. Peter Shore Court DS0000052366.V290442.R02.S.doc Version 5.1 Page 22 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 ENVIRONMENT CHOICE OF HOME Standard No Score 1 2 3 4 5 6 Standard No 19 20 21 22 23 24 25 26 Score 3 N/A 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 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 3 3 3 3 3 Peter Shore Court DS0000052366.V290442.R02.S.doc Version 5.1 Page 23 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 OP9 Regulation 13(2) Requirement The Manager must ensure the accurate recording of the administration of medicines in the Medication Administration Record sheets (MAR). The timescale of 31/01/06 was not met. The Manager must ensure that expired medicines returned to the pharmacy within the specified expiry date of the medicine. The timescale of 31/01/06 was not met. Timescale for action 15/05/06 2 OP9 13(2) 15/05/06 Peter Shore Court DS0000052366.V290442.R02.S.doc Version 5.1 Page 24 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 OP20 Good Practice Recommendations The inspector recommends the development of a garden in the space available at the back of the home. Peter Shore Court DS0000052366.V290442.R02.S.doc Version 5.1 Page 25 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.V290442.R02.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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