Inspection on 18/06/08 for Shirebrook House

This inspection was carried out on 18th June 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 18 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 17/08/09

Shirebrook House 02/12/08

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 28/09/2008.

CARE HOME ADULTS 18-65 Shirebrook House 19 Station Road Borrowash Derbyshire DE72 3LG Lead Inspector Nancy Bradley Unannounced Inspection 18th June 2008 09:00 Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 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 Shirebrook House DS0000067849.V366554.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 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. Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shirebrook House Address 19 Station Road Borrowash Derbyshire DE72 3LG 01332 725734 0114 2691133 shirebrookhouse@shirebrookcaregroup.co.uk 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) Shirebrook Care Limited Manager post vacant Care Home 10 Category(ies) of Learning disability (10), Physical disability (10), registration, with number Sensory impairment (10) of places Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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 The maximum number of service users who can be accommodated is 10 1st December 2007 2. Date of last inspection Brief Description of the Service: 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 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 Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. 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 eight hours. We spoke with the manager, care staff and people living at the home. 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) that was sent to us by the home. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the home. Two people living at the home were 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 scare plans and other documents relating to that persons care, talking to staff regarding the care they provide and if possible talking to the person. Additionally, time was spent in preparation for the visit, looking at the service history and the previous inspection report. Records were examined relating to the people living there and the general running of the home. There were eight people living at the home on the day of the visit, the home currently has two vacancies We sent out nine “Have Your Say” questionnaires to people living at the home and have received none back. We received five completed questionnaires from staff stating the lack of suitable management, poor team support and low staff moral has being their concerns. We have received no questionnaires from relatives. What the service does well: The home was comfortable in appearance, was maintained to a good standard and set in a residential part of the town. Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 6 The home is offering good choices to people living at the home as how they can spend their day. The activities are appropriate to the needs and abilities of the people living at the home. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 7 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. Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 8 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 Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are now in place to ensure that people’s needs are fully assessed prior to admission EVIDENCE: During the site visit the care plan of the most recent person admitted to the home was examined. The home currently has eight people living there and we had viewed their records at pervious site visits. The majority of the people who are admitted to the home have 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 72 hours after admission and then within the next twelve months. All of the people living at the home have received regular visits from Care Managers within the last six months. Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 10 This inspection had been brought forward from its scheduled dated of December 2008 due to the number of safeguarding and staffing issues. Following the meeting with referring agencies contracts were suspended in April 2008. The suspension has been lifted as of Monday 16th June 2008. The Managing Director Shaun Sunderland has agreed a voluntary hold on future admissions until October. Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Inconsistencies in the care planning system, recording and risk assessments may compromise service delivery. EVIDENCE: The care records of the most recent person admitted to the home was examined. The home currently has eight people living there and we had viewed their records at pervious site visits. The care plan viewed was Shirebrook Group Care corporate documentation, which is based on a nursing model rather than a social care model. As the home is residential and not nursing it was questioned at this site visit and the previous one as to the reasons for this. Care plans had not been development since our last site visit. They were not easy to understand, or to follow as they kept in separate folders and in different parts of the house. There was no evidence to show that people had been consulted about their care. Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 12 On examination of records inconsistencies was noted in care planning, the level of recording and evaluation of care plans. People reported information on care plans is out of date and changes in care do not always get communicated to the staff. Some risk assessments were in place covering such issues as, people’s health and safety, physical health, nutrition, mobility and tissue viability. There was no evidence to indicate that life experiences work had been undertaken with people living at the home. There was no evidence of care plans being formally reviewed on a six monthly basis. The manager is looking to implement new care planning, risk assessments and individual profiles on all people at living at the home. During the site visit we were able to examine the new style care plans. Care plans will be personcentred with an easy read format for people to understand. Daily living notes will be completed on each person by the staff on duty. This will include night staff as well. The manager is compiling the new care plans a long with the key-worker for each person. Each month the manager will monitor the care plans then formally reviewed in conjunction with the referring agency after six months. The manager stated that implementation of the care plans was going to take longer than previous thought. Peoples, families or Advocacy Services are not consulted when drawing up care plans. Development of care plans is indicate in the AQAA as an area they could do better . Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14,15, and 16. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were arrangements in place to enable people to maintain and develop appropriate relationships, and to participate in activities both in the home and outside in the wider community in accordance with their preferences and wishes. EVIDENCE: During the visit we observed people at the home and care staff engaged in activities. Discussions with the activities coordinator confirmed that planning is now taking place regarding people’s social, recreational, educational and occupational activities both within the home and outside in the community. As indicated in the AQAA this is an area where the home has moved on from the previous site visit, by employing a full time experienced activities coordinator. The manager stated that the Shirebrook Care Ltd is opening a training/day centre, which people at the home can access on a daily base. Risk assessments are being developed to cover activities involving people at the home. Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 14 The relationships observed between care staff and people who live at the home appeared open and good-humoured. People at the home indicated they are building good relationships with the care staff. The staff encouraged the people living at the home to take pride in their appearance and their dress sense is respected The daily routines are flexible with every one being able to make their own decisions about how they spend the day. The people living at the home are encouraged to be as independent as possible taking responsibility for some of the household tasks, like tidying their rooms and helping to prepare a meal. Information on peoples’ records indicated that contact with family and friends was 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. At present the people living there do not have access to Advocacy Service. However as indicated in the AQAA this is an area the home is seeking to develop. Several families currently take an active role in their relatives care and are able to act on their behalf. The new cook had just started on the day we visited. Previously the staff had prepared and cooked meals. Menus were fairly balanced however staff have commented that the meals are not always nourishing and fresh vegetables are not routinely used. The manager stated the cook would be compiling new menus in consultation with the people living at the home. Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 20 and 21. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People receive personal support in ways, which enables them to be independent. However inconsistencies in the level of recording of medication may leave people vulnerable and at risk. EVIDENCE: The majority of people who live at the home were not able to express themselves verbally and to contribute directly to the visit. During a tour of the home and through direct observation we noted people appeared to be relaxed, happy and contented. Direct observation indicated that the majority of people required some assistance with personal support, with several of them having a high level of need and support. During the visit it was clear that the peoples’ privacy and dignity were respected, where supervision during personal care is required. However there is an issue of privacy in bedrooms and in some communal areas. This was raised at a previous site visit and is detailed later in the report under the environmental section. Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 16 Discussions with staff indicate that they have satisfactory insight into the needs of individual people and are committed to supporting and assisting them. It is important that there are up to date and detailed records on how peoples’ needs are addressed, and to safeguard them by ensuring that their total needs are identified and responded to. Records examined indicate peoples’ health and personal needs were being met. People were generally healthy and records show that staff promptly contacted the appropriate medical services when necessary. However people living at the home are not routinely accessing annual health checks. Discussion with the manager as to how this could be developed concluded that each person could have his or her own health plan. Information in the AQAA indicated the home is looking to implement a health plan and include this in the persons overall care plan. Annual health checks will be through the local G.P services. 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. The home operates and monitors peoples’ medication, as none of them are able to administer their own medication. All staff are to receive training on medication and administrative procedures. Currently only senior care staff are signed off to administer medication. The arrangements for receipt, storage, administration and disposal of medication were examined and found to be satisfactory at the time of this site visit. However concerns have been raised about the staffs’ level of recoding when administrating medication. Gaps in recording were identified and addressed, by management of Shirebrook Care. The home currently uses a local pharmacy and the gaps in recording had not been noted by them during a recent audit of medication records. Shirebrook Care has negotiated a service agreement with a large pharmaceutical company, which will be undertaking regular audits. The manager will also being undertaking regular checks on medication. The AQAA confirmed the change of pharmacist. End of Life plans have yet to be developed for people living at the home. Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 23 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to safeguard peoples’ welfare and ensure that their concerns are listened to and acted upon. However the lack of training in safeguarding may leave people vulnerable. EVIDENCE: People living at the home are made aware of the home’s complaints procedure through the service user guide. A copy is displayed on the home’s notice board in an easy to read format. Any concerns and complaints made by people living at the home or their relatives are investigated within the agreed time scales. The manager maintains a record of all complaints made by people, details of the investigation action and outcome. The complaints procedure contains the current contact details of the Commission for Social Care Inspection 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. We have not received any formal complaints from people or their relatives about their care since the site visit. The home has received one compliant about its service; this was dealt with in the correct manner. The home’s policy on Safeguarding Adults was examined. This is a corporate policy and has been updated to cover Safeguarding of Adults. Training records Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 18 indicated that several care staff have not received any training on safeguarding adults. The safeguarding adult’s policy made reference to local procedures, however the contact details for local offices were not included. There has been a number of safeguarding of adults incidents since the last inspection involving care people received whilst living at the home. Derbyshire and Derby City Adult Services Departments have investigated these under their safeguarding adults procedures. As stated earlier in the report contracts were suspended and have now been reinstated. Social Services will continue to monitor through visits and care reviews. The home has agreed to make Social Services aware of any problems they may have in the future. The home has a separate policy for whistle blowing and it was under this policy the safeguarding issues were raised. 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. The manager stated that several families have retained reasonability for their relative’s finances. Information in the AQAA indicated that the home has set up a new system for managing people’s monies. Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The general standard of the home and the environment are good providing people who live there with an attractive and comfortable place in which to live. EVIDENCE: We carried out a tour of the home, accompanied by the manager. All communal areas were inspected together with staff facilities. Peoples’ bedrooms were viewed with their agreement and all rooms had been decorated and furnished to their personal choice and were being personalised The family of one person have 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. Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 20 As discussed with the manager several of the bedrooms and communal rooms look out on to the street, with the majority of the rooms having blinds fitted to the windows. However, these are pulled up and in the day and do not allow the people any privacy from the street. This was raised as an issue at the previous inspection. The manager informed us that additional blinds were being fitted the following day. 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. Although all care staff require the training on procedures. The AQAA confirmed that training on Infection control is outstanding. A new full time cook/cleaner has just been appointed Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,33, 34, 35 and 36. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of suitable trained, competent and experienced staff may adversely affect the care people receive and as a result the service quality in this outcome area is poor. EVIDENCE: At present the home is not meeting the requirement of fifty percent qualified staff. The home has twelve staff with five qualified and two working towards the NVQ level 2 or above. One staff member reported they had been told they could not access NVQ training. Issues from the safeguarding identified that the home had not always been able to have sufficient staff to meet the needs of the people living there. Information in the AQAA indicates that the responsibility for rotas is with the manager. Previously staff had changed shifts without authorisations and were not turning up for work. Staffing levels severely restricted the care people received, as they could not access activities in the community due to the lack of staff or their understanding of their needs.. Discussions with people from the home indicate that staff were not undertaking their allocated duties and care tasks. Staff questionnaires indicate they were Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 22 always under staffed and not able to give one to one care to the people who needed it. On the day we visited the home had one male senior carer, two female care assistants, the activities coordinator and the cook. The manager is supernumerary to the numbers. The home is looking to employ a deputy manager and have relief staff to cover for staff sickness. There has been an issue with staff going off sick at short notice. Discussion with staff confirmed that staff meetings had not always taken place and when they did issues discussed were not always appropriate and did not allow for staff participation.. People reported this had been the case for a while and had not improved even when the temporary management arrangements had been put in place. People reported that communication between the management and care workers could be improved. The home has a recruitment and selection policy in place. Several staff records were examined and all the required information was on record. However the overall presentation of staff files was poor. Records were not indexed and all papers were loose in the file. All staff have a current Criminal Records Bureau check, and are required to provide 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. The home is not routinely maintaining a record of staff interviews held. Discussion with staff confirmed they had completed an application form and had been interviewed for the post they held. Discussions with staff, records and completed questionnaires confirmed that staff have received little or no training. This includes induction and any further developmental training they may wish to undertake. One staff member indicated they had not been introduced to the people living at the home when they started another stated they had undertaken their own distance learning. Discussions with staff and from records seen confirmed they had not always received formal supervision. People reported they had been at the home for three months and never received any supervision. They were relying on other staff to guide them and this was not always helpful as there was subtle bullying of new staff. The new manager has complied a supervision schedule for the next few weeks so that staff receive an initial supervision. As discussed at the site visit a formal system for supervision needs to be established. This has been identified in the AQAA as an area requiring improvement. Discussions with Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 23 staff confirmed that the new manager is approachable and has an open door policy. People stated they found him supportive however generally2 staff morale is low.2 Staff said, “The situation is slowly getting better. However unless there is a dramatic change within the home, staff retention will be an issue again.” Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 and 42. Quality in this outcome area is poor. This judgement has been made using available 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: Since the home has been registered they has been a number of changes in manager. The registered manager resigned in November 2007, a new manager was appointed, then resigned, and now another new manager has been appointed. He has been in post for three weeks at the time of this site visit. The new manager has yet to submit his application for registered manager status to the Commission for Social Care Inspection, and register for a recognised Registered Managers Award He currently has a NVQ level 3 in care. Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 25 The Registered Provider has undertaken no formal quality assurance since the site visit of May 2007. Previous site visits have highlighted this shortfall. The AQAA indicates quality assurance is area they could do better, consult more with people living at the home and hold regular house meetings. The new manager has an open door policy and is available to speak with people’s families at any time. Discussion with staff and completed staff questionnaires indicate that staff have some insight to the issues, which need to be addressed by the managements of Shirebrook Care Ltd. “The lack of meaningful supervision of staff; the gender in balance of staff when people need one to one care; the 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 failed to turn up for work; the atmosphere and bullying of new staff; induction training for all staff; developmental and specialist training opportunities.” The Regulation 26 visits are to be carried out by the Financial Director, and the appropriateness of this was discussed with the Managing Director in view of their lack of management and care experience. This is contradictor to the information in the AQAA, which indicates the Group Care Manager, or the Operations Manager will undertake theses. There was no evidence to show that Regulation 26 visits have bee undertaken or that management issue, have been identified or fully addressed by Shirebrook Care Ltd since the previous site visit. The parents of people living at the home are quite active and have set up their own Advocacy / Support group. The AQAA dataset indicated that all the necessary maintenance of equipment checks had been undertaken however the dates for these were not recorded. Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 26 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 Standard No Score 1 X 2 3 3 X 4 2 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 1 33 1 34 2 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 2 1 X 1 X X 2 X Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 27 YES 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 YA6 Regulation 15 Requirement Comprehensive individual care plans must be developed for each person to demonstrate their assessed need and to ensure they will be receive the appropriate level of care. This is a previous requirement. Individual plans of care must be drawn up with the involvement of the person, family or advocate where appropriate so that they are aware of their care needs. This is a previous requirement. The Registered Person must ensure that suitable curtains are provided to the windows that are street facing to ensure people privacy. This covers both peoples’ bedrooms and any communal rooms. This is a previous requirement. The home must establish and maintain a system for reviewing the quality of care provided to people using its service. This is a previous requirement. Meals must be complied which DS0000067849.V366554.R01.S.doc Timescale for action 31/08/08 2. YA6 15 31/08/08 3. YA24 16 31/08/08 4. YA39 24 31/12/08 5. YA17 16 31/08/08 Page 28 Shirebrook House Version 5.2 6. 7. YA23 YA32 13 and 18 18 are nutritional balance and take account of people likes and dislikes. All staff must complete training on the Safeguarding of Adults. The Registered Provider must ensure the homes as sufficient numbers of qualified staff to meet the needs of the people who live there. The Registered Provider must ensure there is sufficient numbers of staff to meet the assessed needs of the people who live there. The Registered Provider must have suitable management support to assist the manager with day-to-day running of the home. The Registered Provider must have sufficient staff to cover for staff sickness, to ensure that people whom live there are cared for appropriately. The Registered Provider must ensure that regular staff meetings take place. All staff must have a period of induction before they commence their duties. The Registered Provider must ensure that all staff receive the appropriate training to undertake the duties they are employed for. All staff must receive regular supervision. The Manager must submit an application to be registered with the Commission for Social Care Inspection. A suitable person must undertake monthly provider visits. DS0000067849.V366554.R01.S.doc 31/10/08 31/08/08 8. YA33 18 31/07/08 9. YA33 18 31/07/08 10. YA33 18 31/07/08 11. 12. 13. YA33 YA35 YA35 18 18 18 31/08/08 31/08/08 31/12/08 14. 15. YA36 YA37 18 10 31/08/08 31/10/08 16. YA39 26 31/07/08 Shirebrook House Version 5.2 Page 29 17. YA39 26 18. YA42 23 Copies of the monthly provider 31/12/08 visits must be sent to the Commission for Social Care Inspection until the end of the year. The Registered Provider must 31/07/08 provide evidence of when the maintenance checks were carried out. 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. 5. 6. Refer to Standard YA7 YA21 YA35 YA35 YA34 YA37 Good Practice Recommendations Each person at the home should have access to Advocacy Services Each person living at the home should have an end of life plan. The Registered Person should undertake some team development as a way of addressing staff issues. This is a previous recommendation. All should undertake training on the Mental Capacity Act 2007. This is a previous recommendation. Staff records should be indexed and presented in an organised format. The manager must register and complete a recognised managers award. Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Shirebrook House DS0000067849.V366554.R01.S.doc Version 5.2 Page 31 - 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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