Inspection on 17/08/09 for Shirebrook House

This inspection was carried out on 17th August 2009.

CQC found this care home to be providing an Poor service.

The inspector found no outstanding requirements from the previous inspection report, but made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shirebrook House 20/11/09

Shirebrook House 02/12/08

Shirebrook House 18/06/08

Shirebrook House 01/12/07

Shirebrook House 02/03/07

Similar services:

Hillside

Applegarth

122 Scorer Street

St Marys Nursing Home

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report Care homes for adults (18-65 years) Name: Address: Shirebrook House 19 Station Road Borrowash Derbyshire DE72 3LG     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Nancy Bradley     Date: 1 7 0 8 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 33 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 33 Information about the care home Name of care home: Address: Shirebrook House 19 Station Road Borrowash Derbyshire DE72 3LG 01332725734 01142691133 shirebrookhouse@shirebrookcaregroup.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Shirebrook Care Limited care home 10 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability physical disability sensory impairment Additional conditions: The maximum number of service users who can be accommodated is 10 The registered person may provide the following categories of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are: Learning disability - Code LD Physical disability Code PD Sensory Impairment - Code SI Date of last inspection Brief description of the care home The Care home is situated in the village of Borrowash, which lies on the Derbyshire and Nottingham boarder and owned by the Shirebrook Care Limited, which is a privately owned company. The home provides residential care for ten adults, whose primary needs include sensory impairment, learning and physical disabilities. The building is a detached house situated on a residential housing estate in Borrowash close to local amenities. The accommodation is spacious and has been adapted to meet the needs of the people Care Homes for Adults (18-65 years) Page 4 of 33 Over 65 0 0 0 10 10 10 0 2 1 2 2 0 0 8 Brief description of the care home who will live there. Facilities for service users are located on the ground and first floor; the staff and sleeping in room is located on the second floor. The home has ten single bedrooms with en-suite facilities; all rooms except for two rooms have shower facilities. The dining and lounge areas, kitchen, laundry and conservatory are on the ground floor. A `walk in shower room and a bathroom with a bath and tracking hoist are located on the ground floor; the three bedrooms on the first floor have en-suite shower facilities. Information on fees was not available Care Homes for Adults (18-65 years) Page 5 of 33 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 0 stars. This means the people who use this service experience poor quality outcomes. This was an unannounced key inspection and took place over a total of six hours. We spoke with the Responsible Individual, care staff and members of Family Carers Group. The inspection activity during this site visit was to assess the service against the key National Minimum Standards and these are identified through the report. We looked at all the information that we received or asked for, since the last key inspection. This included the following: The Annual Quality Assurance Assessment (AQAA). On the 28th August the Responsible Individual requested an extension to the AQAA . This was given and the AQAA is do to be returned on the 11th Sept 2009. Records relating to the general running of the home were also viewed. Care Homes for Adults (18-65 years) Page 6 of 33 One person at the home was case tracked. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at care plans and other documents relating to that persons care, talking to staff regarding the care they provide and if possible talking to the person. The inspection was caried out following two safeguarding meetings convened by Derby City Adult Social Services Department. At the time of this site visit people who were resident in the home had moved to alternative accommodation. There were two inspectors and one pharmacist inspector at this site visit. The site visit started on the 12th Sept with further visits on the 13th and 17th September. Care Homes for Adults (18-65 years) Page 7 of 33 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 33 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 33 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements are now in place to ensure that peoples needs are fully assessed prior to admission. Evidence: On the day of this site visit people from the home had been transferred to alterative accommodation. The majority of the people who had been admitted to the home had their needs assessed through the care management system, which highlights their additional needs, and the need for additional staffing hours. The home also undertakes its own individual comprehensive needs assessment and which is in accordance with Shirebrook Care Ltd assessment process and the National Minimum Standard 2.3. The assessment then forms part of the care plan compiled by the home. There was evidence on file to show that the care needs assessment of the person had been reviewed by the referring agency. All of the people who had live at the home had received regular visits from Care Managers within the last six months. Care Homes for Adults (18-65 years) Page 10 of 33 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a care planning and review system in place, which ensures that peoples individual needs are addressed. Evidence: On the day of this site visit people from the home had been transferred to alterative accommodation. The home made the care records of the people who had lived there available to us. During this vist we viewed the care records of one person. The manager had compiled the care plan and evidence was seen of care plans being reviewed on a regular basis. The person had care plan, which was in accordance with their assessed need and formulated within a risk assessment. All care plans provided details of peoples individual lifestyle preferences and choices; the interventions prescribed by outside healthcare professionals were appropriate. Daily and night records are also maintained on each person who lived at the home. However there were inconsistencies in daily and night recording. Care Homes for Adults (18-65 years) Page 11 of 33 Evidence: The home has established a formal annual reviewing system with the referring agency. The information in the care plans has improved since the last site visit and gives staff a direction on how they are to deliver care. Care plans have been explained to the people living at the home and they have signed where possible that they agree and understand. In cases where they are not able to sign, a family member has done this Risk assessments were in place covering issues such as, peoples health and safety, physical health, nutrition, mobility, behaviour management and risks associated with social activities. Risk assessments were are also monitored and updated as required. There was no evidence to indicate that life experience work had been undertaken with people living at the home. All of the people at the home have access to the local Advocacy Services. The Family Carers Group is very active within the home. Several of the families are responsible for their relatives finances. Care Homes for Adults (18-65 years) Page 12 of 33 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of meaningful activities may seriously harm peoples abilities to develop independent life skills and maintain appropriate links with the local community. Evidence: On the day of this site visit people from the home had been transferred to alterative accommodation. There were no activities at the time of this site visit. There have been three activities coordinators employed by Shirebrook Care Group in the last two years. The Family Carers Group expressed serious concerns about the lifestyle and the lack of activities over the eighteen months. They had raised there concerns with Shirebrook Care Group Ltd who promised that people would be able to access the new day centre at Long Eaton. The Family Carers Group stated these promises went on and on. At a meeting with Shirebrook Care Group Ltd the families were told that a new activities Care Homes for Adults (18-65 years) Page 13 of 33 Evidence: coordinator would not be appointed, the manager and staff would arrange these and a driver would be employed for ten hours a week. Discussion with staff indicated this was very difficult and on one occasion they were told they could not access the centre at Long Eaton as it had been hired it out to paying clients. The Family Carers Group were told that the people from Shirebrook House would be given priority. This was one of the main reason families had chosen Shirebrook House as their relatives had previously attended day centres five days per week. People have been taken for holidays this was arranged by the previous manager and families have covered the cost. Staff have arranged activities; however this has been limited to taking people to the park or to the shops. Time and staffing being the barriers to anything more meaning full being arranged. The family of one person arranged their own activities rota. Information on peoples records indicated that contact with family and friends were appropriate. Any restriction on contact is to be recorded in care plans. People at the home can speak with family and friends and receive mail. People at the home have access to local Advocacy Services and families take an active role in their relatives care and are able to act on their behalf. The cook is responsible for compiling the weekly menu. The hot meal is prepared and then finished off by the care staff. From observations and discussion with family and care staff, this was based on the people being out on activities however this appears not to working very well. Records seen and from discussions with the cook indicated that food temperatures were not always being recorded by the care staff after completing the evening meal. Also the cook was without a food probe for three months. This was brought to the attention of the homes management team. At weekends the staff prepare snack style meals and people have a take away and information received indicates they are charged for this. The cook works from 10am to 2pm Monday to Friday.. One person was on a special diet and the families brought the food as Shirebrook House were unable to facilitate this. Care Homes for Adults (18-65 years) Page 14 of 33 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive personal support in ways, which enables them to be independent. However inconsistencies in the administration of medication may leave people vulnerable and at risk. Evidence: On the day of this site visit people from the home had been transferred to alterative accommodation. Discussions with staff indicate that they have satisfactory insight into the needs of individual people and were committed to supporting and assisting them. This was further supported by the Family Carers Group who stated that the staff were very caring, committed to their relatives and have worked long hours to ensure their personal safety and well-being. The home is recording all visits made by people at the home to the G.P.s opticians, podiatry, dentists, audiologist, and speech and language therapist. However there was no clear audit on medical records. The records on peoples weight and hospital appointments are recorded and kept separate to the health care plan. Care Homes for Adults (18-65 years) Page 15 of 33 Evidence: There were no medicines in the building but we saw that suitable cupboards were available for the storage of medicines, including controlled drugs and medicines requiring refrigeration. The medicine policy and written procedure for handling medicines was up to date and easy to follow. We talked to four members of staff and asked about their experience and training in medicines administration. Two staff were senior support workers and were trained and authorised to administer medicines. These two staff members worked fifteen hours a day and gave night time medicines before leaving the home at the end of their shift. We found that two carers, with previous experience of handling medicines, administered medicines if a senior support worker, or other person able to give medicines, was not on duty. We looked at the recent medication administration records of people who had been living in the home. We noted that one person had not received a prescribed medicine for three days as it could not be found. Another person had not been given one of their medicines for two days, and the reason for this had not been written down. We found that the specialised medical needs of another person were described in their care plan. However, insufficient staff were trained in responding to this persons needs in an emergency to ensure that a trained member of staff was always on duty. End of Life plans have yet to be fully developed. Care Homes for Adults (18-65 years) Page 16 of 33 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The current practice operated by Shirebrook Care Group Ltd may leave people vulnerable and at risk of abuse. Evidence: On the day of this site visit people from the home had been transferred to alterative accommodation. The home maintains a record of all complaints made by people, details of the investigation action and outcome. However there was one complaint on file which was dated the 15th April 2009 which indicated that no investigation or outcome had been undertaken. The complaints procedure contains the current contact details of the Care Quality Commission and informs the complainants that they are able to contact the Commission at any stage of the complaints process if they wish to do so. The Care Quality Commission have not received any formal complaints from people or their relatives about their care since the site visit. However the Family Carers Group have made a formal compliant about the reduction of staffing hours imposed on Shirebrook House by the senior management of Shirebrook Care Group Ltd. We have been given copies of the complaint and other concerns raised by the Family Carers Group. Care Homes for Adults (18-65 years) Page 17 of 33 Evidence: The homes policy on Safeguarding Adults has been seen at previous site visits. This is a corporate policy and has been updated to cover Safeguarding of Vulnerable Adults. Training records indicated that several care staff have received training on safeguarding adults. Training for the new staff was scheduled The safeguarding adults policy made reference to local procedures; and indicates the home operates to Derbyshire Adult Social Services Vulnerable Adult Procedures. There has been two safeguarding of vulnerable adults meetings called by Derby City Adults Social Services involving care people received whilst living at the home, the poor staffing levels and the lack of management support. As a result of the first safeguarding meeting and Derby City Adult Services appointed a support worker to the home. Information received from the support worker and from concerns raised by the Family Carers Group lead Derby City to reconvene the safeguarding meeting. Contracts with Shirebrook Care Group Ltd were cancelled and people from the home were accommodated to live elsewhere. The home has a separate policy for whistle blowing however staff indicated that they do not feel comfortable in implementing or following this policy. None of the staff have received training on physical interventions. The system for dealing with peoples personal monies was not fully inspected at this site visit. Care Homes for Adults (18-65 years) Page 18 of 33 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The general standard of the home and the environment would provide an attractive and comfortable place in which people could live in. Evidence: On the day of this site visit people from the home had been transferred to alterative accommodation. We carried out a partial tour of the home; the Responsible Individual was present. All communal areas were inspected together with staff facilities. As the home is now a unoccupied peoples personal belongings had been removed. The family of one person had purchased furniture for their bedroom. The home was clean, well maintained, well furnished, equipped and well lit and heated. There is a central kitchen and separate laundry and staff facilities. All of the bedrooms are single with en-suite facilities. Blinds have been fitted to the windows which look out on to the street. The home has a conservatory and a small garden / patio area, which is not fully utilised. There are no outstanding maintenance issues. The home has a working lift. The home has satisfactory hygiene procedures in place. Staff had not undertaken training on infection control procedures. A full time cook has been appointed. The waking night staff are responsible for doing Care Homes for Adults (18-65 years) Page 19 of 33 Evidence: cleaning and laundry. Care Homes for Adults (18-65 years) Page 20 of 33 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Low staffing levels and the lack of clarity of staff roles may adversely affect the care people receive and service delivery. Evidence: On the day of this site visit people from the home had been transferred to alternative accommodation. Issues from the recent safeguarding meeting held and from concerns raised by family carers identified that the home had not always been able to have sufficient staff to meet the needs of the people living there. The staff and family carers were informed that the staffing numbers would be reduced from four to three per shift. Staff spoken with confirmed that on occasions there were only two on duty and as a consequence people were left unsupervised. Discussion with staff indicated at weekends they have to do the general cleaning, prepare and cook meals and care for the people at the home. Staffing levels have severely restricted the care people received, as they could not access activities in the community due to the lack of staff. One staff member was sent to cover the day centre at Long Eaton leaving the home short of care staff. Staffing rota are not easy to understand, as the home shows people who are either on leave, off sick, or suspended available for work. It appears that there are more staff Care Homes for Adults (18-65 years) Page 21 of 33 Evidence: available than there actually are. Prior to the site visit serious shortfalls in staffing were identified and were being monitored by Placing Authorities and resulted in a safeguarding plans being implemented. Staff reported that there had been one staff meeting since the manager had left with another meeting scheduled for the 4th August 2009, this had been cancelled. No explanation was given to the staff and the Responsible Individual did not know why it had been cancelled. Staff spoken with during the site visit indicated that the staff meeting did not cover issues relating to people care needs but concentrated more on management issues. People reported that communication between the senior management and care workers was poor. The home has a recruitment and selection policy in place. Several staff records were examined and all the required information was on record. All staff have a current and valid Criminal Records Bureau check, two personnel references. As part of providing a full employment history staff records seen provided the days, date month and year. Previously applicants were only providing months and years. All staff are subject to a six months probationary period. Interview records for the most recently appointed staff member were viewed and it was noted that the interview questions had not been signed or dated. Discussion with staff confirmed they had completed an application form and had been interviewed for the post they held. A completed application and Criminal Records Bureau check showed the home was recruiting a sixteen year old worker. The rota also shows them on shift. This information was passed to the Responsible Individual to investigate. The training matrix seen at this site visit was the one we viewed at the inspection in Decembers 2008 and has not been updated. Training for the new staff was not shown, although the Responsible Individual reported that training on safeguarding was scheduled for the forth coming week. New staff had not received any induction training. Staff have not undertaken any Makaton training even though this was offered free by placing authorities. The training matrix showed one member of staff had undertaken this training prior to working at the home. Staff have not received any form of supervision since the manager left in May. The newly appointed staff are not aware of what supervision entails. Staff indicated that the last manager was supportive and the situation was getting better,however the manager did not like helping out with care when they were short of staff. Care Homes for Adults (18-65 years) Page 22 of 33 Evidence: The supervision records of one person indicated the manager had placed a member of staff on waking nights. The staff member had been placed on permanent days following disciplinary actions. The only record of this was in the supervision notes which clearly shows the change in work pattern had been agreed since January 2009. However there is no evidence to confirm this had been signed off by a senior manager although they were aware of the situation. The member of staff was allowed to continue working after further incidents were reported and was only suspended when Derby City brought this to Shirebrook Care Group Ltd attention. Care Homes for Adults (18-65 years) Page 23 of 33 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of an adequate management structure and shortfall in staffing demonstrates the home is not being run in the best interest of the people who live there. Evidence: On the day of this site visit people from the home had been transferred to alterative accommodation. Since the home has been registered they have been a number of changes in manager. The only registered manager resigned in November 2007, with numerous managers having since been appointed however none have stayed or been registered with the Care Quality Commission. The most recent manager left in May 2009 having been at the home for eights months. Temporary management arrangements where put in place, however there is little evidence to indicate that these arrangements would ensure the home was run effectively. The information we received from the Responsible Individual indicated that the Operations Manager would be taking over the management and running of the home. However staff spoken with during the inspection, from rotas seen and from discussions with the family carers groups the level of management support and availability was unclear. Care Homes for Adults (18-65 years) Page 24 of 33 Evidence: The Registered Provider has yet to undertake any formal quality assurance of its service. The families of the people, who lived at the home, did meet regularly with the senior management of Shirebrook Care Group Ltd and were increasing concerned about the lifestyle and staffing of the home. The meetings were bi-monthly then changed to monthly. Family Carers stated that the senior management were aware of their concerns and kept giving assurances that the home situation would improve. Minutes from the Family Carers meeting indicated this had been the case for nearly two years. Discussion with staff indicated that staff have some insight to the issues, which need to be addressed by the senior management of Shirebrook Care Group Ltd. The lack of meaningful supervision of staff; the gender in balance of staff when people need one to one personnel care; an unstable period experienced by both staff and people living at the home; people living at the home not knowing who is going to be caring for them as staff are having to work long hours; the atmosphere of bullying and intimidation of staff; poor communication from management at all levels; new staff not receiving any formal induction; developmental and specialist training opportunities. The Care Quality Commission have not received any Regulation 26 visits reports since 31st March 2009 the one previous to that was the 4th February 2009. We were given a copy of the report dated 12th May 2009. There was no visit carried out in April 2009. Records seen at the site visit indicated no fire checks or fire drills had been undertaken at the home within the last eight months. This was brought to the attention of the Responsible Individual. All other health and safety checks were satisfactory at the time of this site visit. However the staff rota did not identify who was the first aid person. Care Homes for Adults (18-65 years) Page 25 of 33 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 26 of 33 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 16 16 The Registered Person must ensure that people have a healthy balanced and nutritious diet at all times. This must include weekdays and weekends. This is to ensure peoples well-being and to ensure their individual preferences are catered for. The Registered Provider must maintain a record of food temperatures under Food Hygiene regulations. This is to ensure all meals served meet the required standard. 30/09/2009 2 17 16 30/09/2009 3 20 13 Sufficient numbers of staff 30/09/2009 who are competent in all aspects of medicines administration (as determined by the needs of people living in the home) must be on duty at all times. Care Homes for Adults (18-65 years) Page 27 of 33 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is to ensure people receive their medication at the prescribed times or as when required. 4 20 13 Only staff who are authorised and whose competency has been assessed and documented must be permitted to administer medicines. This is to ensure people are fully protected. 5 20 13 Medicines must be 30/09/2009 administered as prescribed, unless otherwise directed by a healthcare professional. This to ensure people receives their correct medication. 6 22 18 All staff must receive training on safeguarding prior to them commencing rota duties. This is to ensure staff have a clear understanding on safeguarding vulnerable people. 7 22 22 All complaints made must be 30/09/2009 investigated within the agreed timescales and the complainant informed or the out come. 30/09/2009 30/09/2009 Care Homes for Adults (18-65 years) Page 28 of 33 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is to ensure peoples views are listened to and acted upon. 8 33 19 The Registered Provider must ensure there is a sufficient number of staff, skills mix and gender balance to ensure the full activities and operation of the home is carried out effectively. This is to ensure people are fully supported by a sufficient, competent and qualified staff. 9 35 18 All new staff must receive structured induction training before they commence rota duties. This is to ensure staff have the appropriate skills to care for people. 10 35 18 All staff must receive additional training to assist in their personal; development and to meet the individual needs of the people they care for. This is to ensure staff have the appropriate skills to care for people. 30/10/2009 30/10/2009 30/10/2009 Care Homes for Adults (18-65 years) Page 29 of 33 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 11 36 18 The home must complete any disciplinary actions which are outstanding and inform the Care Quality Commission of its findings. This is to ensure only suitable people are employed to work at the home. 30/10/2009 12 36 18 All staff must receive recieve 30/10/2009 formal supervision in line the National Minimum Standard 36.4. This is to ensure staff are fuly supported. 13 37 9 The home must have an experienced, qualified and registered manager in place before the home is in full operation. This is to ensure the effective running of the home. 31/12/2009 14 39 24 The Registered Provider must undertake formal quality assurance and quality monitoring of its service. This is ensure the development of the home and to ensure the home meets its aims and objectives. 30/12/2009 Care Homes for Adults (18-65 years) Page 30 of 33 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 15 39 26 The Registered Provider 30/09/2009 must undertake a visit to the home at least once a month and prepare a written report and ensure a copy is supplied to the Care Quality Commission.. This is to ensure the home is running effectively. 16 42 23 The Registered Provider 30/09/2009 must ensure that regular fire drills and fire checks are carried out and recorded in the homes fire log. This is to ensure the safety and welfare of the people who live at the home. 17 43 13 The Registered Provider must ensure that there is a qualified first aider on duty at all times and this person is clearly identified as such on the rota. This is to ensure the safety and welfare of the people who live at the home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 30/10/2009 1 6 For consistency in recording the daily and night records Page 31 of 33 Care Homes for Adults (18-65 years) Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations should form part of the care plan and not be separate to it. 2 3 6 12 There should be more detail and information in the daily and night records. The Registered Provider should provider suitable activities on a daily basis for the people at the home to be engaged in. The home should compile a daily activities programme in consultation with families and Placing Authorise. The home should employ a suitable person to organise daily activities The Registered Provider should re assess the working hours of the cook so they are available to provide a hot meal. All issues relating to peoples medical health should be recorded in the health care plan. End of life plans should be complied on all of the people who live there. The home should develop a policy and procedure on whisleblowing which staff can relate to and feel comfortable in following. The home should employ a full time cleaner. The home should only employed staff who are within the age limit as designated in the National Minimum Standards 32.4. The Registered Provider should undertake some team development as a way of addressing on going staff issues. This has been an on going recommendation. The home should meet on a regular basis with its full staff team. The Registered Provider must seek views of Placing Authorises, people who use the service, and their representatives The Registered Provider must make public its findings. 4 12 5 6 7 12 17 18 8 9 21 23 10 11 30 33 12 33 13 14 36 39 15 39 Care Homes for Adults (18-65 years) Page 32 of 33 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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