Care Home: Pat Shaw House

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What the care home does well Residents have an overall positive experience of the service they receive at Pat Shaw House. Residents comments of the home include, "everything`s handy", "I like it here, it is easy going and you can do as you like". Residents describe staff as being "very nice" and "always available". Residents` needs are adequately assessed prior to their admission. The ethos of the home promotes the individual and diverse needs of each resident. Specific cultural or religious needs are explored during assessment and accommodated, where possible, after placement. Good care plans are in place which effectively identify residents` needs. Staff show residents respect and provide them with support in a way which preserves their privacy and dignity. Social activities are provided which are stimulating, engaging and rewarding to residents. Residents are consulted about and are happy with their meals. Residents express a high level of satisfaction with the service leading to a low number of complaints. Pat Shaw House is a safe, pleasant and well-maintained environment for the residents. Staff are appropriate in numbers, sufficiently skilled and provided with ongoing support and training to meet the needs of resident. A robust staff recruitment procedure is in place to promote the safety of residents. This is a well managed home, enabling the service aims and objectives to be met and ensuring the overall outcomes for residents are good. Systems and procedures in place and monitored and reviewed to ensure the home functions well on an ongoing basis. What has improved since the last inspection? One requirement at the last inspection for staff to make records of daily activities with residents more explicit in service users` files has been met. This is a well operating home. The Manager informs that staff are more knowledgeable about how to meet residents` needs. This is reflected in the low turnover of staff, creating a more stable, motivated and effective team who are more knowledgeable and therefore more likely to meet individual residents` needs. There are consistently few complaints. There are more internal reviews, consistent monthly evaluations and improved case recording. Compliments to the service are received by residents, families and closely involved professionals. What the care home could do better: Supervise and provide training as may be required for individual staff to ensure that residents` health care assessments are accurately completed, reviewed and updated to reflect residents` current needs. Improve the monitoring of staff activities to ensure safe medication practises are in operation at all times. Staff must be reminded that prescribed repeat medicines should be ordered in advance of when needed. Staff must consistently maintain good health and safety practises for the protection of all residents. CARE HOMES FOR OLDER PEOPLE Pat Shaw House 50 Globe Road Bethnal Green London E1 4DS Lead Inspector Nurcan Culleton Unannounced Inspection 10:00 30th and 31 October 2007 st 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.V353849.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.V353849.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 audrey.parathan@excelcareholdings.com Excelcare Management Limited 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.V353849.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th May 2006 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 ensuite bedrooms and six en-suite double bedroom flats, two located on each floor. 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. The service fees are £504 per week, though this is currently under review. Pat Shaw House DS0000052367.V353849.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 over two days on 30th and 31st October 2007, with the assistance of the Manager, staff and residents at Pat Shaw House. The inspection process involved a tour of the premises; examination of staff and residents’ files, key records and documents required by regulation and interviews with residents and staff to assess the overall quality of service according to the service as experienced by the residents. It also takes into account the Annual Quality Assurance Assessment (AQUAA) completed by the home. What the service does well: What has improved since the last inspection? One requirement at the last inspection for staff to make records of daily activities with residents more explicit in service users’ files has been met. This is a well operating home. The Manager informs that staff are more knowledgeable about how to meet residents’ needs. This is reflected in the low turnover of staff, creating a more stable, motivated and effective team who are more knowledgeable and therefore more likely to Pat Shaw House DS0000052367.V353849.R01.S.doc Version 5.2 Page 6 meet individual residents’ needs. There are consistently few complaints. There are more internal reviews, consistent monthly evaluations and improved case recording. Compliments to the service are received by residents, families and closely involved professionals. What they could do better: 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. The summary of this inspection report can be made available in other formats on request. Pat Shaw House DS0000052367.V353849.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.V353849.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1-6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and interested parties have access to good information about the service provision at Pat Shaw House. Residents’ needs are adequately assessed prior to their admission. Residents can be assured that the ethos of the home promotes the individual and diverse needs of each resident. EVIDENCE: The home has in place a Statement of Purpose and Service Users’ Guide, both of which have been revised. These documents are available in braille, large print and other languages if requested, as stated in a notice on display. Signed statements by residents show that they have received their own copies. Pat Shaw House DS0000052367.V353849.R01.S.doc Version 5.2 Page 9 Most of the residents are funded by the local authority and one resident is privately funded. The Manager, seniors or team leader undertake preadmission assessments and the admissions process is going smoothly. It is recommended that discussion or actions taken at the admissions meeting is recorded. The home effectively responds to the individual and diverse needs of the people who use the service. The home ensures effective communication with other professionals if further assistance is required to meet these diverse needs. One resident who is fairly independent has an electric wheelchair to promote and maintain his independence. A pastor from the Catholic faith visits the home on a weekly basis. Other residents attend religious services of their own choice in the community, such as mosques, either with their own family members, or with staff. The activities board also contains a notice on display providing information about a special monthly Sunday service for residents at a local church. Specific cultural or religious needs are explored during assessment. One Turkish resident, for example, enjoys drinking Turkish coffee which staff make for her. A compliments folder contains several grateful comments from relatives. One relative stated: “excellent communication, by far the best residential home in Tower Hamlets”, and another commented that their relative loves every moment of being in Pat Shaw. Birthday parties are particularly appreciated by the relatives regarded as special occasions by the residents. Compliments are also received by email to the home. Pat Shaw House DS0000052367.V353849.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7-11 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents’ care plans are good and effectively identify residents’ individual needs. Staff show respect to residents and provide them with support in a way which preserves their privacy and dignity. Staff must observe the correct use of health care assessment forms to ensure that residents’ needs are accurately recorded. The home must ensure that prescribed medicines are ordered in advance for residents at all times. EVIDENCE: The more recently admitted residents have a care plan index at the front of their file detailing all the documents contained within the file. This provides a helpful check-list to assist with the audit of files and with tracking key documentation required for all residents. It could improve the service further and provide more consistency if this practise is extended to all residents’ files. Pat Shaw House DS0000052367.V353849.R01.S.doc Version 5.2 Page 11 Care plans are sufficiently detailed, comprehensively outlining residents’ needs. Residents’ personal care, continence, mobility, mental state, nutrition, medication, senses, night care, pressure sore or wound care, social care and acute or end of life care are each assessed and reviewed on a monthly basis. The home consults with residents about their needs and plans are each signed and dated by the residents and their key worker to confirm joint agreements with plans. However the Excelcare care plan forms are not formatted to include sexual issues; finance; religious and cultural needs of residents. Whilst it is evident that the home meets such needs where relevant to individual residents, it is recommended that Excelcare revise these forms to include these areas within the care plans in order to ensure that such assessed needs are fully specified in residents’ care plans. Whilst care plans identify residents’ preferences in some areas of their needs, this is not consistently applied. One persons’ care plan identifies a need for assistance with bathing or showering. However the frequency of when to bathe or shower the resident according to her preference is not identified, leaving uncertainty about this in the recorded care plan. It is recommended that the frequency with which residents wish to be showered or bathed is identified and recorded in their care plan. It was suggested that deviations from this frequency, according to the residents’ wish on the day, could be recorded in the residents’ daily notes and their care plan reviewed and updated according to any consistent change to the care plan. Residents’ files show contact with health professionals, including the GP, district nurse, optician and dentist, recording details of their health checks. Files contain a range of assessments to further identify residents’ health care and personal care needs, for example nutritional risk assessments, weight charts and pressure care assessments. However a continence assessment completed by the key worker of one resident identifies the resident as being doubly incontinent which is inconsistent with her care plan and daily records. The Manager informed that it was likely that this continence assessment had been completed following a ‘one off’ occasion when the resident may have been incontinent. The Manager advised that staff will be reminded of the appropriate use of these health care assessment forms. Information recorded in the assessment forms of three other residents’ files are consistent with the residents’ needs identified in their care plans. Medication sheets were accurately completed at the time of inspection. Risk assessments are in place and signed by residents if they wish to manage their own medicines. However, several tubs of residents’ creams kept in locked cabinets in the bathrooms were not labelled. Staff had been writing residents’ names in black pen on spare tubs in the home when the resident’s own creams had run out. Staff must urgently be reminded to ensure that residents’ prescribed repeat medicines, including creams, are ordered in advance and that the practise of using spare creams in the home is discontinued. Pat Shaw House DS0000052367.V353849.R01.S.doc Version 5.2 Page 12 Previous inspections to the home demonstrate that the Manager effectively addresses issues raised in inspections with staff and responds promptly to meeting requirements. Staff show respect to residents and provide them with support in a way which preserves their privacy and dignity and residents are shown respect, as observed on the day of inspection. Residents’ views are sought in the way they wish to be treated and in the service they receive. Examples include how there is a shower curtain in each bathroom as requested by some residents. Despite being supported with bathing, these residents prefer to have privacy when they dress or undress and staff will wait outside the bathroom until the residents are ready when this is the case. Residents are consulted about the clothes they wish to have when staff purchase clothes for them. Other examples include how residents’ choose the times they wish to go to bed; are consulted about whether they wish to hold their own keys; whether they wish to vote and a personal items inventory is completed for residents providing a log of their personal possessions. Residents’ views are respected when they request for their family members to be fully consulted about their care. Staff complete a social care assessment for each resident providing information about the residents’ likes and dislikes, their personal interests, including their hobbies and favourite TV programmes. Residents have statements in their files, signed by themselves or their relatives to state the arrangements they wish to be observed apon their death. Pat Shaw House DS0000052367.V353849.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Pat Shaw House ensures that social activities are provided which are stimulating, engaging and rewarding to residents. Residents maintain existing links with their families or friends. Residents enjoy their meals and are fully consulted about them. EVIDENCE: Residents at Pat Shaw have varying support needs and those who are more independent use Dial-A-Ride to go into the community to places of their own choice, for example, to go shopping. Several residents also use Dial-A-Ride to attend a local day centre which provides social activities for older people. Residents also participate in a range of social activities within the home, as arranged by the Activities Coordinator who works in the home from Monday to Thursday during the week. An activities notice board is displayed in the hallway on all three floors. Staff undertake activities with residents over the weekends. A wheelchair accessible mini-bus is available for hire from Tower Hamlets. Pat Shaw House DS0000052367.V353849.R01.S.doc Version 5.2 Page 14 Residents have been to the zoo in the bus since the last inspection. A positive development at Pat Shaw House has been the introduction of a project called Magic Me involving children and young people and the residents of the home, who helped to set up the project. The project involves young people engaging older people in drama, poetry, visual and other arts. At the time of the inspection, one project session was underway and residents were observed to be highly engaged and stimulated in the arts activities they shared with the children. The children’s cultural backgrounds varied reflecting the diverse population of the local area, bringing into the home a sense of participation within the local community. One resident was observed knitting a scarf. She stated that she likes knitting and informs the Activities Coordinator what wool she needs and this is bought for her. However the Manager informed that there are insufficient local community resources to meet the needs of residents of all cultural backgrounds, for example the lack of Turkish day centres for one Turkish resident. The resident in this case had been given the option to move to another borough where more culturally appropriate facilities are available, however the resident has chosen to remain in Pat Shaw House despite this. As stated within this report, staff accommodate her expressed cultural wishes wherever possible, such as by making Turkish coffee for her. Residents maintain their existing family contacts or friendships prior to their admission. Some residents have significant relationships with individual family relatives to whom they hand over full responsibility for decision making over their affairs, such as handling forms or any formal communications with the home. In one case, for example, a needs identification form outlining residents’ likes and personal interests, contained sparse information. The Manager informed that this was the only information provided by the residents’ son who was entrusted by the relative to deal with such forms. However the residents’ file does not record anywhere details of this significant relationship nor of this understanding between the resident, the home and the son. It is recommended that informal agreements between residents, family members and the home concerning the handling of residents’ affairs is detailed in residents’ files. It is also recommended that a policy and procedure is developed for staff in completing residents’ assessments and records and of working with the resident when family members are fully involved in their care. Currently one person manages their own money. Responsibility for managing the other residents’ finances rests with the head office and with the Local Authority. However some of the residents are able to part manage their money, for example, by doing their own shopping for toiletries, paying the hairdressers or for spending money on leisure activities. Some residents also go out shopping with their relatives if they choose. Pat Shaw House DS0000052367.V353849.R01.S.doc Version 5.2 Page 15 Residents are well consulted about their food choices and the menu is displayed on residents’ notice board on each floor. Meals are varied and nutritious and separate records are kept of variations to meals eaten from the menu. Pat Shaw House DS0000052367.V353849.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16-18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A satisfactory complaints procedure is in place, residents are made aware of how to complain and there are a low number of complaints. Residents have their legal right to vote respected and the home promotes the safety and protection of residents. EVIDENCE: Residents are informed about the complaints procedure and expressed no complaints or dissatisfaction when asked on the day of inspection. There have been two complaints since the last inspection in May 2006. One concerns a repair which took a long time to be addressed. An external contractor was used and the Manager was on leave during this time. However this was subsequently followed up with the contractor and appropriate action was taken. It was noted that whilst the complaints procedure is satisfactory, the process could improve further by recording whether residents are satisfied or not with the outcome to their complaint. Pat Shaw House DS0000052367.V353849.R01.S.doc Version 5.2 Page 17 Complaints form part of the Statement of Purpose and Service Users’ Guide, seen in residents’ rooms. A complaints and adult protection policy and procedure is in place in the home. Residents tend to vote using the postal voting method. Those residents who do not wish to vote sign their voting cards to evidence that they wish to decline the vote. Residents sign when receiving their personal allowance. There are dedicated notice boards throughout the home providing information about adult abuse and protection, including indicators of adult abuse and on display a “CareAware” helpline” and advocacy service in addition to the local social care team telephone number. A random sample of residents finances examined showed that the balance of monies checked were correct at the time of inspection. Pat Shaw House DS0000052367.V353849.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19-26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Pat Shaw House is furnished and decorated to create a pleasant and homely environment for the residents. It is a well-maintained, clean and safe home with sufficient facilities to suit the shared and individual needs of its residents. EVIDENCE: The environment is pleasantly decorated encouraging a homely atmosphere for residents. The walls are adorned with pictures and photographs of the residents. The inspector was informed by staff that the Activities Coordinator puts up different pictures on the walls to provide interest and variety to the residents. Pat Shaw House DS0000052367.V353849.R01.S.doc Version 5.2 Page 19 Each person has their own en suite room, all observed to include residents’ personal effects. There are also two large ensuite rooms/flats on each floor, each with separate bedrooms, which can be used as double rooms by couples or if requested and available to others. There are sufficient washing and toilet facilities in the home. Each floor has an assisted bath. Hoists and aids, such as raised toilet seats and rails were observed throughout the home for individual residents’ needs following occupational therapy assessments. Each ensuite room is fitted with emergency cords. Lockable drawers are available to residents who choose to have them to store their valuables or medication. There is a dining room/lounge on every floor, each of which are comfortably furnished, clean and tidy. The ground floor lounge has access to the garden. A piano is situated in the ground floor lounge. The main kitchen is on the ground floor and was clean and tidy on the day of inspection with health and safety procedures adhered to. The garden is well maintained with wooden tables, chairs and plants. There is a well- maintained laundry room and a sluice facility. There is good heating and lighting in the home and water temperatures are regularly checked. The home maintains a good standard of cleanliness and is free from offensive odours. Pat Shaw House DS0000052367.V353849.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff are appropriate in numbers and sufficiently skilled to meet the needs of residents at Pat Shaw House. Staff are provided with appropriate support, training and development to effectively carry out their duties. A robust staff recruitment procedure is in place to promote the safety of residents. EVIDENCE: There are sufficient numbers of staff to meet the needs of the residents who are appropriately qualified and trained to perform their duties. Currently there are 30 health care assistants, 4 seniors and 1 team leader. There are 6 care staff in the morning and 5 carers in the afternoon per shift. There is also a senior on each shift who is also trained in first aid. Overnight there is 1 senior and 2 carers, who are all wake-in staff. Internal staff are used to cover for staff absences and the home is recruiting for additional bank staff. Pat Shaw House DS0000052367.V353849.R01.S.doc Version 5.2 Page 21 When prompted on the day of inspection, staff showed good knowledge of individual residents’ needs and were observed to engage with residents and appropriately provide them with support. There are monthly staff meetings and separate monthly meetings between the Manager and seniors. Four staff files examined contained all documentation required to demonstrate that thorough recruitment procedures are followed. In many cases, staff have prior experience of working in the home after serving a period of voluntary work there. Once employed, the Manager follows the Skills For Care induction workbook with the newly recruited employee to ensure that staff have the necessary competencies to work with residents. Over 90 per cent of staff have NVQ Level 2 qualification. In addition, each staff member has a personal development folder. These include personal development plans, identifying staff training needs linked to the aims of the business, competencies needed and how the identified training need will be met. Certificates of staff training are available in staff files. A training matrix is also used by the Manager to input training received by individual staff. The Manager gives regular supervision to her seniors who in turn give regular supervision to the carers. Annual appraisals are underway. Staff speak positively about the Manager and how the home is managed. One staff member likened working in the home as “being in one big family”. Residents spoke of the staff as being “very nice” and “always available”. This is reflected in the low turnover of staff, creating a more stable, motivated and effective team who are more knowledgeable and therefore more likely to meet individual residents’ needs. Pat Shaw House DS0000052367.V353849.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31-38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. This is a well managed home, enabling the service aims and objectives to be met and ensuring the overall outcomes for residents living in the home are good. Systems and procedures in place and are monitored and reviewed to ensure the home functions well on an ongoing basis. EVIDENCE: The Manager has an NVQ Level 3 and a Registered Managers’ Award. She has long standing experience of working in and managing the home. Staff inform that the Manager is competent and is always available, approachable and helpful. Pat Shaw House DS0000052367.V353849.R01.S.doc Version 5.2 Page 23 The Manager has monthly supervision by the Responsible Individual. In turn the Manager has regular supervision with the seniors who regularly supervise the carers. The Manager ensures that she maintains effective communication on the ground, talking to residents, families as well as staff, thus familiarising herself with residents’ needs; monitoring staff performance and how systems and procedures work in practise. In this way, the Manager has a strong presence in the home, discovering first hand any issues that may require prompt attention and directing the action appropriately. As a result, there are few complaints; satisfied residents; good staff morale and a good level of compliments received in the home. Residents comments of the home include, “everything’s handy”, “I like it here, it is easy going and you can do as you like”. The Manager or senior conducts monthly random care plan and health and safety audits and weekly medication audits seen on the day of inspection. Issues arising are raised with seniors in the monthly seniors’ meeting in the first instance and with individual staff members if necessary. Monthly reports are also produced by the Manager providing information about complaints; POVA; compliments; accidents; pressure sore audits; including treatment or action taken; critical residents’ information; monthly staff training; monthly staff supervision; professional enquiries; weekly audits and outstanding maintenance issues. Monthly monitoring visits and reports are also conducted by the Responsible Individual, however the reports were not available in the home on the day of inspection until they were requested by the inspector and subsequently faxed over. A full range of policies and procedures on key matters related to residents are available and regularly reviewed. A business and financial plan is in place. An employers’ liability insurance certificate is available however the home was not able to produce a public liability insurance certificate. It is recommended that the home ensures there is adequate cover to meet any public liability, damage or loss which may be incurred, as specified in The Care Homes Regulations 2001. Health and safety certificates were satisfactory and evidence of daily health and safety, fire alarm and evacuation procedure records were seen. Health and safety practises are generally well observed, with the one exception of one out of date yoghurt found in a residents’ own fridge in their room dated 13th October 2007. The inspector was advised that staff monitor fridges weekly. The Manager informed that this issue will be raised with the staff team to underline the importance of maintaining these regular checks. Pat Shaw House DS0000052367.V353849.R01.S.doc Version 5.2 Page 24 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 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 2 Pat Shaw House DS0000052367.V353849.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13(2) Requirement Timescale for action 14/12/07 2 OP38 13(4) Ensure that residents’ repeat prescribed medicines are ordered in advance and that the practise of using spare creams in the home is discontinued. Ensure that staff maintain good 14/12/07 health and safety practises at all times. 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. 2 3 4 Refer to Standard OP3 OP7 OP7 OP8 Good Practice Recommendations Record key discussions and actions agreed at residents’ admissions meetings. Identify and record the frequency with which residents wish to be showered or bathed in their care plan and review and update accordingly. Excelcare to revise the way care plans are formatted to include sexual/behavioural issues; finance and religious/cultural needs. Ensure staff adequately complete health care assessments DS0000052367.V353849.R01.S.doc Version 5.2 Page 26 Pat Shaw House 5 6 OP12 OP33 to accurately reflect residents’ current needs. Ensure that informal agreements between residents, family members and the home concerning the handling of residents’ affairs are recorded in residents’ files. Ensure a policy and procedure is developed for staff in completing residents’ assessments and records and of working with the resident when family members are fully involved in their care. Ensure there is adequate cover to meet any public liability, damage or loss which may be incurred, as specified in The Care Homes Regulations 2001. Include the Care Plan content of documents in each residents’ file. 6 OP34 7 OP37 Pat Shaw House DS0000052367.V353849.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V353849.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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