Inspection on 04/10/05 for The Shires Care Centre

This inspection was carried out on 4th October 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Shires Care Centre 01/06/07

The Shires Care Centre 02/06/06

The Shires Care Centre 25/04/05

The Shires Care Centre 07/06/04

The Shires Care Centre 05/06/03

The Shires Care Centre 26/09/02

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Shires Care Centre The Oval Sutton In Ashfield Nottinghamshire NG17 2FP Lead Inspector Karmon Hawley Unannounced Inspection 4th October 2005 10:00 Shires Care Centre DS0000024660.V251398.R01.S.doc Version 5.0 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 Shires Care Centre DS0000024660.V251398.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 Adults 18-65. 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. Shires Care Centre DS0000024660.V251398.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Shires Care Centre Address The Oval Sutton In Ashfield Nottinghamshire NG17 2FP 01623 551099 01623 550788 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) Mr S A Zaman James William Hanson Care Home 42 Category(ies) of Physical disability (42) registration, with number of places Shires Care Centre DS0000024660.V251398.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25/04/05 Brief Description of the Service: The Shires is a care home providing accommodation, personal and nursing care for 42 service users aged 18-65 with physical and associated learning disabilities, it provides long-term and planned respite care in single rooms with ensuite facilities and was opened in 1996 and is owned by Mr Zaman, who also owns a number of other homes. it is located in the centre of a residential estate which is supported by bus links into the main town of Sutton in Ashfield. The home is close to local facilities and amenities and the home has a mini bus to facilitate access into the local community. The Shires is a two-storey purpose built building with a lift to the upper floor, all areas of the building are accessible to wheelchair users. Staff actively encourage and facilitate participation, independence and inclusion within the local community. Shires Care Centre DS0000024660.V251398.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day during which four service users case files and other documentation related to care practices and the environment were observed. Four staff members and five service users were spoken with. The staff were helpful towards the inspector and demonstrated a good level of skill and understanding in caring for the service users within the home. What the service does well: What has improved since the last inspection? Many improvements have been made since the last inspection. A staff training plan is now in place to ensure staff have the relevant knowledge and skills to deliver good standards of care. Risk assessments with regards to service users holding room keys are undertaken to ensure service users rights and safety are maintained. A new policy with regards to acting as appointee for service users has been devised to ensure service users are fully protected. A routine maintenance plan is now in place to ensure service users live in a wellmaintained environment. It is now also ensured all staff members have two written references in place to further protect service users safety. A new induction plan has been devised and is due to be implemented within the next few weeks, this will ensure staff are trained at a good standard and will be proficient to deliver a good standard of care. Improvement have also been Shires Care Centre DS0000024660.V251398.R01.S.doc Version 5.0 Page 6 made with regards to the service users plans of care to ensure these are in depth and service user focused ensuring needs are fully met. 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. Shires Care Centre DS0000024660.V251398.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shires Care Centre DS0000024660.V251398.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not assessed during this inspection. Shires Care Centre DS0000024660.V251398.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 Service users know their assessed and changing needs and personal goals are reflected in their individual plan, however safety may be compromised due to the lack of appropriate risk assessments and photographic identification of service users. EVIDENCE: Service users undergo various assessments with regards to daily activities, risk, social and recreational needs. The information gained from these assessments form the basis of the plan of care. Plans of care are personalised, service user focussed and in depth. Complex needs are identified and a relevant plan of care in place. Risk assessments with regards to manual handling, falls and others significant to the service users were in place, however within two files examined there was no risk assessment with regards to the use of bed rails and entrapment. Social assessments had taken place to ensure service users are facilitated in living a life of their choice and preferences are maintained, there was evidence of this occurring within progress notes. Progress notes are completed on a daily basis and significant events are documented. Service users spoken with were aware of plans of care in place and stated their needs are fully met. Shires Care Centre DS0000024660.V251398.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15,17 Service users are able to take part in appropriate activities and maintain appropriate personal, family and sexual relationships. Service users are offered a healthy diet and enjoy their meals and mealtimes, however safety may be compromised due to the lack of documentation with regards to hazard analysis critical control points. EVIDENCE: There are two activities coordinators working with service users and a varied plan of activities is arranged during service users meetings. Activities take place in groups and on an individual basis according to the level of service users needs and preferences. The inspector observed a group of service users undertaking a session of arts and crafts and one service users spoken with had been purchased a scrap book so she may make her own portfolio, she was very pleased with this. Several service users attend the day centre and college and undertake studies of their choice. One service user also has a job within the community. Staff facilitate service users to access these services and gain employment if required. There are no restrictions on visiting and service users may choose who they wish to see. If desired relatives are involved in service users meetings and Shires Care Centre DS0000024660.V251398.R01.S.doc Version 5.0 Page 11 their plan of care. Visitors can be received in private should it be desired and personal relationships are dealt with accordingly. A varied menu is on offer and service users are given choice at each meal, service users spoken with were able to substantiate this and stated food was plentiful and at a good standard. Food and drink is provided at intervals throughout the day and services users also have access to drink making facilities should they choose to use them. Due to the size of the kitchen and health and safety issues service users do not access the kitchen, however baking days do take place in the dining room for service users to join in. Documentation within the kitchen was observed and all records were up to date. The kitchen was clean and tidy and there was evidence of stock rotation taking place. Although a hazard analysis plan is in place staff do not record checks that have taken place to demonstrate these are followed. Shires Care Centre DS0000024660.V251398.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Service users receive personal support in the way they prefer and require. Physical and emotional health needs are met. Service users are able to retain, administer and control their own medication where appropriate and are protected by the homes policies and procedures in place. EVIDENCE: Further training has taken place since the last inspection and more has been arranged to continue to promote professional relations between service users and staff. Service users may choose who tends to their personal needs and staff are trained and instructed in these areas. Each service user has undergone a manual handling assessment which staff are aware of to ensure manual handling is performed according to service users preference and safety is maintained. The routines within the home are stated to be flexible which both service users and staff spoken with substantiated. All appropriate equipment and aids are available within the home. Service users are facilitated and enabled to control their own health care needs, escorts by staff of the home are provided if necessary. Relevant services are accessed within the community and specialists also visit the home if required. Evidence of this occurring was available within service users case notes. Appropriate and up to date information is made available to service users with regards to current health care issues. Service users spoken with stated they were able to access services as required. Shires Care Centre DS0000024660.V251398.R01.S.doc Version 5.0 Page 13 Service users may administer their own medication following a risk assessment. There was evidence of this within one service users file examined and an appropriate policy was in place. Authority had also been sought from the service users general practitioner. The manager is currently looking at additional training for registered nurses to ensure they remain up to date with current issues, senior care assistants have undertaken training with regards to the safe administration of medications. Medication on the day of the inspection was satisfactory and medication checked with the service users prescription chart was correct. Appropriate checks and documentation were maintained to a satisfactory standard. Shires Care Centre DS0000024660.V251398.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not assessed during this inspection. Shires Care Centre DS0000024660.V251398.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 The home is clean and hygienic. EVIDENCE: There are sufficient domestic staff employed to maintain the cleanliness of the building. All areas observed were clean and tidy and free from malodour. The laundry room was inspected and had appropriate equipment in place. Staff have undergone training with regards to infection control and were able to discuss practice and were observed wearing protective clothing. Shires Care Centre DS0000024660.V251398.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not assessed during this inspection. Shires Care Centre DS0000024660.V251398.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 Service users benefit from a well run home. EVIDENCE: The acting manager has been in post for six months and is awaiting her fit person application to be completed. She is able to demonstrate good knowledge and skill in her area of work and has relevant qualifications and skill for this position. She ensures she maintains an open atmosphere where service users and staff are able to approach her should it be required. She actively supports and facilitates staff development and training. Regular staff and service users meetings are held to ensure each has a voice and their opinions are taken into consideration. Staff and service users spoken with spoke very highly of the acting manager and stated that the home is well run. Shires Care Centre DS0000024660.V251398.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Shires Care Centre Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X X X DS0000024660.V251398.R01.S.doc Version 5.0 Page 19 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YP6 Regulation 13(4,c) Requirement The responsible individual is required to ensure appropriate risk assessments with regards to the use of bed rails and entrapment are in place to fully protect service users. The responsible individual is required to ensure that photographic identification of service users is in place with service user consent to ensure correct identification and safety. The responsible individual is required to ensure that the environmental health officer is liaised with to ensure the safe receipt, storage, preparation, cooking and serving of food is analysed. Timescale for action 05/11/05 2 YP6 17(1,a) schedule 3 05/12/05 2 YP17 16(2,h) 05/01/05 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 Shires Care Centre DS0000024660.V251398.R01.S.doc Version 5.0 Page 20 Shires Care Centre DS0000024660.V251398.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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. 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