Inspection on 02/12/08 for Shirebrook House

This inspection was carried out on 2nd December 2008.

CSCI found this care home to be providing an Adequate 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 12 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 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 13/03/2009.

Inspecting for better lives 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:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Nancy Bradley     Date: 0 2 1 2 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. the things that people have said are important to them: They reflect 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. 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 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 34 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 34 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): Name of registered manager (if applicable) Shirebrook Care Limited Type of registration: Number of places registered: 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 Care Homes for Adults (18-65 years) Page 4 of 34 Over 65 0 0 0 10 10 10 Brief description of the care home 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 Care Homes for Adults (18-65 years) Page 5 of 34 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: one star adequate 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 1star. This means the people who use this service experience adequate quality outcomes. six 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. Care Homes for Adults (18-65 years) Page 6 of 34 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 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. 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 one completed questionnaires from staff stating the lack of suitable management, poor team support has being their concerns. We have received no questionnaires from relatives. 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 set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get Care Homes for Adults (18-65 years) Page 8 of 34 printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 34 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 10 of 34 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements are place to ensure that peoples needs are fully assessed prior to admission. However the lack of comprehensive assessments may compromise service delivery. 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 viewed their records at previous 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 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. However there was no evidence on record of the home undertaking an assessment of the persons needs prior to Care Homes for Adults (18-65 years) Page 11 of 34 Evidence: admission. We were informed that this was a planned admission from September. The assessment from the placing authority referred to the previous placement and was dated 2006. There was evidence on file to show that the care needs assessment of the person had been reviewed by the referring agency following their admission to the home. All of the people living at the home have received regular visits from Care Managers within the last six months. This is a second key inspection of the home following the zero rating of the home in June of this year. The Managing Director, Shaun Sunderland agreed in June to a voluntary hold on future admissions until October 2008. However the home admitted a person in September three weeks before this voluntary suspension of admissions expired. Care Homes for Adults (18-65 years) Page 12 of 34 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 adequate quality outcomes in this area. We have made this judgement using a range of 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 and we had viewed their records at pervious site visits. Care plans are now in place however they still require more details and information. The care plans were indexed and in a chronological order. However information data and front sheets had not been completed. For example we had to read pervious paperwork to find out when the person was admitted. The care plan viewed was dated 17th November 2008 the person was admitted on the 8th September 2008 indicating a two month gap in the planning and delivery of his care. The responsible individual informed us that an interim care plan was in place however we were not shown this at Care Homes for Adults (18-65 years) Page 13 of 34 Evidence: the time. The stated manager she is compiling the new care plans along with the keyworker for each person. The manager will monitor the care plans and then formally review them in conjunction with the referring agency after six months. There was no evidence to indicate that life experiences work had been undertaken with people living at the home. The care staff had completed daily living and night records on each person. Risk assessments were in place, these needs to show actions staff should take after the risk has been identified and assessed. Also additional areas of risk need to be assessed and included in peoples records, for example tissue viability and any identified medical condition. These need to be updated and reviewed in line with care plans. Care Homes for Adults (18-65 years) Page 14 of 34 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 good quality outcomes in this area. We have made this judgement using a range of 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 new activities coordinator confirmed that planning is now taking place regarding peoples 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. Shirebrook Care Ltd has opened a training,day centerer, which people at the home access on a daily base. The care staff from the home take people to the day center which has a cafe and pool. On the day of the visit Care Homes for Adults (18-65 years) Page 15 of 34 Evidence: people were going to the day center then on their return had a musical sing-along. The manager stated that the day center maintains individual risk assessments and care plans on the people who attend from the home. However care staff spoken with during the visit had little knowledge of the content of the care plans. People attendance at the day center is dependant on them having a staff member who can drive the mini bus. 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 unopened. Only one person at the home has access to computers. 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. A new cook has just started and has developed a new menu based on the peoples likes and dislikes. Previously the staff had prepared and cooked meals. People at the home indicated they were happy with the meals. Care Homes for Adults (18-65 years) Page 16 of 34 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 adequate 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 health care plans and risk assessments 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 still is an issue of privacy relating to two bedrooms and a landing area next to a bathroom. This has been raised at previous site visit and is detailed later in the report under the environmental section. Care Homes for Adults (18-65 years) Page 17 of 34 Evidence: Discussions with staff indicate that they have limited insight into the needs of individual people and are committed to supporting and assisting them. However the health plan for one person did not make reference to his medical condition and nor was there a risk assessment in place. 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 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. 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 has information sheets where all visits made by people at the home to the G.P.s opticians, podiatry, dentists, audiologist, and speech and language therapist, can be recorded. The home operates and monitors peoples medication, as none of them are able to administer their own medication. Currently only senior care staff are signed off to administer medication. However concerns have been raised about staff ability to administer medication and several staff have been retrained in medication procedures following errors in medication. Concerns have also been raised about care staff leaving the medication trolley open and unattended. The manager has introduced new procedures. During the site visit we observed a medication round and staff are now following procedures. We did note that the trolley is brought out and left locked at least five to ten minutes before the medication round is due. The arrangements for receipt, storage, administration and disposal of medication were examined and found to be satisfactory at the time of this site visit. The medication trolley and cupboard is better organised than we have previously seen. 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. End of Life plans have yet to be developed for people living at the home. Care Homes for Adults (18-65 years) Page 18 of 34 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 adequate quality outcomes in this area. We have made this judgement using a range of 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 homes complaints procedure through the service user guide. A copy is displayed on the homes 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. We received a concern, regarding medication and the use of personal mobile phones by the staff. This was passed on to the home for them to investigate under their procedures and to report back their finding. As yet we have not received this report. Care Homes for Adults (18-65 years) Page 19 of 34 Evidence: The homes policy on Safeguarding Adults was examined. This is a corporate policy and has been updated to cover Safeguarding of Adults. Training records indicated that several care staff have not received any training on safeguarding adults. Information from the manager has confirmed that four of the staff group have received training with the remaining staff booked on training for thee 5th Jan 2009. The safeguarding adults policy made reference to local procedures, however the contact details for local offices were not included. Following the safeguarding of adults incidents earlier in the year Derby City Adult Services Departments continue to monitor the home through visits and care reviews. 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. Many of the families have retained reasonability for their relatives finances. Information in the AQAA indicated that the home has set up a new system for managing peoples monies. Care Homes for Adults (18-65 years) Page 20 of 34 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 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. The home had fitted blinds to the majority of the windows in the home however there are still windows were they have not. As discussed with the manager two bedrooms and a landing window next to the bathroom on the first floor look out on to the street and peoples privacy cannot be fully met. We acknowledge that the bedrooms were not being use at the time but the bathroom is in use. This has been raised at previous site visits. Care Homes for Adults (18-65 years) Page 21 of 34 Evidence: 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 satisfactory hygiene procedures in place. Although several care staff still require training on procedures. The AQAA confirmed that training on infection control is outstanding. Information from the manager indicates this is booked for the 5th Jan 2009. The Environmental Heatlh Departmnet has recently inspected the home and following their inspection left a Statutory Notice. They found evidence of mice infestation in the kitchen. The home was already dealing with this before they visited. The Environmental Health will be undertaking a follow up visits. A new full time cook has been appointed however the home is still without a full time cleaner. The waking night staff undertake the majority of the cleaning. Care Homes for Adults (18-65 years) Page 22 of 34 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has recruitment and selection procedures in place to ensure that the appropriate staff are employed to care for vulnerable people However people living at the home would be better supported with an effective staff team who are appropriately trained. Evidence: Information from at the time of the site visit indicates the home is not meeting the requirement of fifty percent qualified staff. The home has a total of fifteen staff, six staff holding a NVQ level 2 or above, two working towards the NVQ level 3. Further staff have been nominated for NVQ level 2 and 3 in the new year. On the day we visited the home had one male and one female senior carer, two female care assistants, the activities coordinator and the cook. The manager is supernumerary to the numbers. At the previous inspection Shirebrook Care confirmed they were looking to appoint a deputy manager, they decided not to do this but promote a senior carer to a team leader. The manager stated they try to have four staff on but on occasions there has only been two. Care staff are going off sick at weekends and at short notice. Discussions with care staff and from completed questionnaires indicated staffing number for each shift could be better. Care Homes for Adults (18-65 years) Page 23 of 34 Evidence: Discussion with staff confirmed that staff meetings are now taking place. Although staff still reported that communication between the senior management and care workers could be improved. The home has a recruitment and selection policy in place. Several staff records were examined, with the majority of the essential information on record. Since the previous site visit work has been undertaken on presentation of staff records. Records are now indexed and there are no lose papers on file. All staff have a current Criminal Records Bureau check, and are required to provide two personnel references. Recruitment records seen indicated applicants were not always providing a full employment history. Also one person had been appointed with out a medical declaration. All staff are subject to a six months probationary period. The new manager has appointed four new care staff and is maintaining a full record of staff interviews. Discussion with staff confirmed they had completed an application form and had been interviewed for the post they held. Discussions with staff and completed questionnaires confirmed that staff have received little or no training. This includes formal on site induction and any further developmental training they may wish to undertake in order to do their job for example training in Mackaton. Information provided by the manager states that from the 29th Sept new starters have received a full induction this included two weeks shadowing and a full Shirebrook Care Ltd induction pack which takes over six months to complete and currently five care staff are working through this. Further information from the manager stated three staff have had moving and handling training, with some staff booked for more training on the 7th Jan 2009, and two more to do an intensive course half day course on the 19th Jan 2009. There are five staff who have completed first aid training and three more are booked for 20th Dec 2008, with the remaining staff group booked on the 7th Jan 2009. Three care staff have completed fire training with the remaining staff booked on 5th and 7th of Jan 2009. This information indicates the majority of the staff all seem to be training on the same day. Discussions with staff and from records seen confirmed that all staff have received one formal supervision since the manager started in Sept. The manager confirmed further Care Homes for Adults (18-65 years) Page 24 of 34 Evidence: supervisions are booked. This was identified in the AQAA as an area requiring improvement. Discussions with staff confirmed that the new manager is approachable supportive, and operates an open door policy. Care staff indicated staff morale slowly getting better. In previous reports we have recommended team building, and we still strongly recommend this. Care Homes for Adults (18-65 years) Page 25 of 34 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of a permanent and purposeful management structure and team demonstrates the home is not always being run in the best interest of the people who live there. Evidence: Since the home has been registered there has been a number of changes in manager. The registered manager resigned in November 2007, a new manager was appointed, then resigned, now another new manager was appointed and then resigned. A new manager started in Sept 2008. The new manager has yet to submit their application for registered manager status to the Commission for Social Care Inspection. The new manager has a recognised Registered Managers Award and holds a NVQ level 4 in care. 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 an 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 peoples families at any time. There is a very Care Homes for Adults (18-65 years) Page 26 of 34 Evidence: active family support group who meet regularly with the management. Discussions with staff indicate that they have some insight into the issues, which need to be addressed by the management of Shirebrook Care Ltd. Several staff stated they had seen changes to the home since the new manager started. For example care plans are now in place for all of the people and staff have received formal supervision. The Operations Manager carries out the Regulation 26 visits. There was evidence to show that Regulation 26 visits have been undertaken and we have received copies of the reports from July and August 2008. Since the site visit we have received a report for October. This was discussed with the Operations Manager and highlighted as an area of concern. The improvement plan states the Managing Director or Group Care Manager would submit these to us each month. The AQAA dataset indicated that all the necessary maintenance of equipment checks had been undertaken however the dates for these were not recorded. At the site visit we requested an update on the AQAA this has not arrived as yet. Care Homes for Adults (18-65 years) Page 27 of 34 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 23 13 and 18 All staff must complete 05/01/2009 training on the Safeguarding of Adults. As training is scheduled for 5th Jan 2009 , this timescales has been extended to cover this action. This requirement had a previous timescale of 31/10/2008, which has not been met. Enforcement action may now be considered. The Registered Provider must 31/12/2008 ensure that all staff receive the appropriate training to undertake the duties they are employed for. As training is scheduled for 20th Dec 2008, 5th ,7th,and 19th Jan 2009 , this timescales has been extended to cover this action. This requirement had a previous timescale of 31/12/2008, which has not been met. Enforcement action may now be considered. Copies of the monthly 31/12/2008 provider visits must be sent to the Commission for Social Care Inspection until the end 31/12/2008. This timescale as not yet expired. . Page 28 of 34 2 35 18 3 39 26 Care Homes for Adults (18-65 years) Care Homes for Adults (18-65 years) Page 29 of 34 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 2 12 The home must have an up to date assessment of the persons individual aspirations and needs. This must be from the care management or by the home prior to admission. This is to ensure the home can meet the persons assessed needs. 30/01/2009 2 2 12 All assessments must be reviewed on a regular basis. This is to ensure the home can continue to meet the assessed need and to assess any changes in care required. 19/02/2009 3 6 12 Peoples care plan needs to 30/01/2009 show how the home is going to care for them. The care plan must include their changing needs aspirations and goals. Care Homes for Adults (18-65 years) Page 30 of 34 This is to ensure people receive the care they require. 4 9 12 Risk assessments must be in 30/01/2009 line with the assessed need and care plan. This is to ensure people are fully supported. 5 19 12 People living at the home must have an annually health check This is to ensure peoples physical and emotional needs are met . 6 21 12 All of the people living at the 30/01/2009 home must have an end of life plan To ensure their death is handled in line with their wishes and with respect. 7 24 16 The registered person must ensure suitable fittings are provided to the two vacant bedroom and landing windows. This is to ensure peoples privacy at all times. 8 33 18 The registered provider 30/01/2009 must ensure there are sufficient staff numbers with complementary skills to care for people when staffing numbers are low due to staff sickness or turnover of staff. This is to ensure there are sufficient numbers of staff to care for people at all times. 27/02/2009 27/02/2009 Care Homes for Adults (18-65 years) Page 31 of 34 9 34 18 All newly appointed staff 30/01/2009 must have a period of induction. This includeds the manager , care and ancillary staff. This is to ensure all staff are aware of the organisation, the experiences and needs of the people they are caring for. 10 34 18 All applicants s must provide 30/01/2009 a full employment history This is to ensure people are fully protected. 11 37 10 The newly appointed manager must submit an application with the Commission for Social Care Inspection. This is to ensure the home has a registered manager who is competent and experienced to run the home. 30/01/2009 12 42 23 The Registered Provider must provide dates that corresponds to the evidence provided of when the maintenance checks have been carried out. A serious concerns letter has been issued requesting this information. 09/01/2009 This is to ensure the health , safety and welfare of the people who live at the home. Care Homes for Adults (18-65 years) Page 32 of 34 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 1 2 3 4 5 6 7 7 12 12 20 20 Care plans and risk assessments should be reviewed on a regular basis. Each person at the home should have access to Advocacy Services. The home should have details of the care plans and risk assessments complied by the day center. All people at the home should have access to information technology. The medication trolley should not be brought out before the medication round is due. The Commission for Social Care Inspection should receive details of the investigation carried out following the concerns expressed about staff administrating medication. Each person living at the home should have an end of life plan. The Commission for Social care inspection should have details of the investigation following the concern raised about staff using mobile phones whilst at work. When providing a full employment applicants should provide the days date month and year. All staff should undertake training on the Mental Capacity Act 2007.This is a previous recommendation. All staff should undertake additional training commensurate to their post. The Registered Person should undertake some team development as a way of addressing staff issues.This is a previous recommendation. 7 8 21 22 9 10 11 12 34 35 35 35 Care Homes for Adults (18-65 years) Page 33 of 34 Helpline: 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 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) Commission for Social Care Inspection (CSCI). 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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