Inspection on 03/12/07 for Shirebrook Priory

This inspection was carried out on 3rd December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 20 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shirebrook Priory 20/11/09

Shirebrook Priory 02/07/09

Shirebrook Priory 26/01/09

Shirebrook Priory 07/08/08

Shirebrook Priory 06/05/08

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Shirebrook Priory Retford Road South Leverton Nr Retford Nottinghamshire DN22 0BY Lead Inspector Stephen Benson Unannounced Inspection 3rd December 2007 09:30 Shirebrook Priory DS0000070803.V355020.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 Priory DS0000070803.V355020.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 Priory DS0000070803.V355020.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shirebrook Priory Address Retford Road South Leverton Nr Retford Nottinghamshire DN22 0BY 01427 884482 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 Group Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Shirebrook Priory DS0000070803.V355020.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The provider may provide the following category of service only: Care Home - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Learning Disabilities - Code LD The maximum number of service users who can be accommodated are: 16. New service Date of last inspection Shirebrook Priory DS0000070803.V355020.R01.S.doc Version 5.2 Page 5 Brief Description of the Service: The Priory is a care home providing personal care and accommodation for 16 younger adults who have a learning disability. The home provides short and long term care and will provide a respite service and accept emergency admissions. The home is owned by Shireborook Care Group who own a number of care homes. The home is located in the village of South Leverton, which has a shop, post office and pubs. There is public transport to the nearby town of Retford and the home has a vehicle to assist with transport. . All of the home’s bedrooms are single, and 6 of the bedrooms have en-suite facilities. Bedrooms are located on 2 floors. There is not a passenger or stair lift. The home has large gardens, including a pond and vegetable garden that are well maintained and easily accessible. There is car parking available for about 10 cars. The operations manager said on 03/12/07 that the fees for the service range from £585.08 - £1524.30 per week depending on dependency needs. Further information about the home is available from the acting manager and will be available from the providers website shortly when the home has been added at www.shirebrookcaregroup.co.uk . A copy of the latest inspection report is available in the office. Shirebrook Priory DS0000070803.V355020.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was the first visit to the home since the change of ownership in October 2007 by The Commission for Social Care Inspection. Prior to the visit an analysis of the home was undertaken from information gathered since the change in ownership including that from the Annual Quality Assurance Assessment they completed. . The visit centred on looking at the key National Minimum Standards for younger adults. The site visit lasted for 6 hours and the main method of inspection used was called case tracking which involved selecting 3 residents and tracking the care they receive through the checking of their records and discussing this with them. An expert by experience joined the visit and assisted with seeking the views of residents. Other residents were spoken with and additional records were seen. A discussion was had with the operations manager, acting manager, staff on duty and care practices were observed. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. The registration certificate was checked and found to be incorrect as it was the one for the previous provider. The acting manager said the new certificate was incorrect and has been sent back to be amended. What the service does well: What has improved since the last inspection? What they could do better: Shirebrook Priory DS0000070803.V355020.R01.S.doc Version 5.2 Page 7 The Statement of Purpose must be kept up to date and accurately reflect the services provided in the home so current and future residents know what they can expect. There must be arrangements in place, which are known by staff, to assess the needs of any prospective new resident so any prospective new resident is properly assessed to establish if their needs can be met in the home. Each resident must have an up to date care plan that clearly describes how his or her assessed needs are to be met. These plans should be drawn up with the involvement of the resident and kept under regular review. Residents must be provided with greater opportunities to make decisions about their lives and suitable communication aids should be used to assist with this. There must be a robust system for assessing any potential risks faced by residents which staff must be familiar with. More frequent and varied activities must be provided. This will ensure that residents have opportunities to spend time doing things they find enjoyable and stimulating. A review of the current catering arrangements should be held to ensure that residents are provided with a balanced, varied and wholesome diet. Personal support must be provided in a manner that promotes residents’ abilities and independence. The home must have a procedure for the safe administration of medicines, which must be followed by staff. This will ensure that residents receive their medication in a safe manner. When it is necessary to handwrite a Medicine Administration Record this must be signed by the person doing so and by another person to confirm they have checked it has been copied correctly. This is to ensure that residents are given the correct medication. A record must be made of any complaint, which includes any investigation and outcome of the complaint. This will ensure that any complaint made by a resident is fully investigated. All residents must be able to access the complaints procedure. This will ensure that all residents are able to make a complaint. All staff must be familiar with the procedures to follow to safeguard residents if there is any suspicion of abuse. This will ensure that staff know how to protect residents. Shirebrook Priory DS0000070803.V355020.R01.S.doc Version 5.2 Page 8 The physical standard of the home must be improved so that residents live in a homely, comfortable and safe environment. There must be a review of the current staffing arrangements to ensure that there are sufficient staff suitably deployed to meet the needs of the residents. The correct recruitment process must be followed at all times, including obtaining a Criminal Records Bureau or Protection of Vulnerable Adults check. This will ensure that residents are protected by the home’s recruitment process. All staff should receive the training they require to be able to meet the needs of the residents. All the required health and safety checks and tests must be carried out within the required timescale to promote the safety of residents. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Shirebrook Priory DS0000070803.V355020.R01.S.doc Version 5.2 Page 9 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 Priory DS0000070803.V355020.R01.S.doc Version 5.2 Page 10 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): 1 and 2 People who use the 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 home is not ready to admit any new residents due to a lack of documentation and preperation. EVIDENCE: There was not a Statement of Purpose for the home available. There have not been any referrals or admissions to the home since the change of ownership and the acting manager said she had not yet looked at the admissions procedure and documentation as she had prioritised other areas as needing attention first. The acting manager said she would expect to meet with anyone who made a referral and arrange to do an assessment to establish whether the person’s needs could be met in the home. Staff said the assessment of new residents and admissions process has not been discussed with them since the change in ownership and they were not aware of any plans for someone to move into the home. Shirebrook Priory DS0000070803.V355020.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): 6, 7 and 9 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents needs cannot be properly met as they are not set out in a plan of care and do not have personal goals. Residents could be far more actively involved in making decisions about their lives and are not supported to take risks. EVIDENCE: A sample of three care files were looked at and these were poorly organised with a lot of old paperwork. There were no signs of them being updated or involving residents and relatives. The acting manager said the care files are to be changed and this is a project she plans to start this week and showed the format to be used. The acting manager said the current care files are not being used really as they are not a useful working file. Staff are however using weekly records that are kept in another office which record what residents do each day. Shirebrook Priory DS0000070803.V355020.R01.S.doc Version 5.2 Page 12 Staff said the care files are kept in the acting manager’s office and they do not have access to them when the acting manager is not there. Staff said they don’t really know anything about the care plans and don’t use them at present but know they are going to be changed to a new format used by the provider in their other homes. One resident repeatedly told the expert by experience “I am autistic. I am mentally handicapped, and I can’t even boil an egg.” The expert by experience felt that staff need to work with the residents with their personal care plans making their lives person centred. The acting manager said that residents make decisions from the moment they get up, about what they would like to do. The acting manager said she is looking to introduce the use of flash and picture cards to assist residents make decisions. Staff said residents choose when they get up and what they want to eat and drink. Staff said some residents will ask to go out and they ask other residents if they want to. One resident will go and get his coat if he wants to go out. Staff said they had covered using picture cards in their National Vocational Qualification training and thought they would help residents make decisions. The operations manager said he felt the opportunities for residents to make choices were restricted historically and opportunities for residents to make choices need to be opened up. The expert by experience did not see any evidence of staff using easy words and pictures or communication aids for residents even those he was told, “Can’t communicate very well.” The expert by experience found that one resident began to communicate with him using easy words and pictures. The expert by experience felt that staff need more training on how to use easy words and pictures and communication aids. The acting manager said they are still using risk assessments from the previous owners and these are very woolly. The acting manager said that so far the risk assessments for two residents have been reviewed and risk assessment is an area to be addressed. Staff said they do not know how to complete risk assessments and they have not had risk assessments discussed with them. Shirebrook Priory DS0000070803.V355020.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): 12, 13, 15, 16 and 17 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents do not have sufficient opportunities for personal development, taking part in leisure activities or being involved with the local community. Catering arrangements are disorganized and residents are not able to make choices. EVIDENCE: There were a group of residents (varying between 6 and 8) congregating in the lounge area after breakfast from about 9.30 am. There was a television on quietly but there was nothing else for resident to do. Staff said that residents sit and relax while they take their breaks before activities start at 10.30 am. Staff said the activity on offer this morning was arts and crafts. One resident asked for a cup of tea and was told he had to wait until 11.00 am when the morning drinks are served. There was little interaction taking place Shirebrook Priory DS0000070803.V355020.R01.S.doc Version 5.2 Page 14 between staff and residents apart from answering any questions residents asked. At 10.15 am. a member of staff asked which residents wanted to go to the crafts room, and some did, however this activity lasted for less than half an hour. There was not another organised activity that morning. The acting manager said she will assess what residents are able to do and be more creative about what residents do during the day and look to find ways to involve them more in the community. Staff said they have been thinking of ideas for things for residents to do as they need a lot more stimulation. The expert by experience felt there was not much for service users to do in the Priory. One resident was asked at lunch what he did in the morning he said, “I watched TV”. When asked what he was doing in the afternoon, he said, “watching TV”. He went on to say “I would like someone to drive me up the A58 to Halifax, or the A62 to Liverpool Cathedral”. The acting manager said residents had been asked if they wanted to go to church but none had said they did. The acting manager said there is not any involvement with the local community including another registered home in the area. Staff said residents do use public transport and one resident told the expert by experience, “I use my bus pass and visit my friends and family in Mansfield” and added “With a member of staff”. Staff said residents go out bowling, horse riding, local walks and visit a café and pub. A record was seen of residents taking part in these activities in daily reports. A resident told the expert by experience he has quality time on Friday’s when a member of staff takes him to Retford for shopping and a pizza. Some residents were having breakfast in the dining room at 9.00 am. Tea and coffee was served from jugs which already had the milk added. One resident was heard to ask for some more tea but was told there was only coffee left. One resident tried to get up from the table but was told 5 times to sit down and finish her toast. The home does not have a menu and the record made of meals provided was not always completed. The cook had to change what she had planned to cook for today’s lunch as the sausages had been used over the weekend and meat taken out was not defrosted. The cook prepared a lunch of steak and kidney Shirebrook Priory DS0000070803.V355020.R01.S.doc Version 5.2 Page 15 or mushroom pie, mashed potato, broccoli, carrots and cabbage with gravy followed by semolina. Examples of other meals provided include liver and sausage, toad in the hole, spaghetti bolognaise and chicken casserole. The cook said she prepares a pudding at lunchtimes but this is not always done when he is not there. The cook said there is always fish and chips on Fridays and a roast dinner on Sundays. The acting manager said changes are needed to the catering arrangements and presentation of meals. The expert by experience said there did not seem to be a choice of menu but the residents seemed to enjoy the food and he did as well. The expert by experience was told by one resident, “I had sausages as I don’t like pie. Shirebrook Priory DS0000070803.V355020.R01.S.doc Version 5.2 Page 16 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): 18, 19 and 20 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff do not take into account residents abilities when providing personal support. Residents healthcare needs are met but they are put at risk by unsafe practices being followed in the administration of medicines. EVIDENCE: During breakfast one resident was seen to make two attempts to talk to a member of staff but was not able to do so as the staff were involved in a discussion between themselves. All residents at breakfast were wearing plastic aprons and no side plates were provided for the toast so residents were using the table. As each resident left the table staff wiped their fingers and face with a wipe. The had one and expert by experience noted at lunch all residents wore plastic aprons and their mouths wiped by staff, whatever their ability. He also noted when resident said he was upset at lunchtime a staff member responded well, tried to find out what the matter was. DS0000070803.V355020.R01.S.doc Version 5.2 Page 17 Shirebrook Priory The acting manager said that there are not any guidelines for staff to follow and she has had to provide guidance to staff on some personal support issues. Staff said they provide support to residents individually and respect their privacy by shutting doors. The expert by experience said when he asked if we could interview a resident, a member of staff invited him into the resident’s room, without asking him. The acting manager said that staff are aware of signs that a resident may be unwell, but that residents are not encouraged to carry out self examinations and some may be able to do this. Staff said that any healthcare provided is recorded in the weekly records. Staff said that residents see a variety of healthcare professionals including doctors, dentists and opticians and some attend well man or woman clinics. Two staff took one resident to a dentist appointment that morning. A resident told the expert by experience he had a health action plan, and visits his dentist often. Part of the morning medication round was observed and at one point a member of staff carried 4 unmarked pots of liquid medication to residents for them to take, two of which were clear. Staff said they had already signed the Medicine Administration Record before taking the medicine to residents. The acting manager said she has arranged to change over to using a monitored dosage system with a different pharmacist who will be providing training to staff on using this. The acting manager said she will be rewriting the safe handling and administration of medicines policy to reflect this change. The Medicine Administration Records were handwritten and had not been signed by the person who wrote them or checked for their accuracy. There were a number of gaps seen and staff did not know why. A member of staff said she has been administering medication for some time but has not had training in the safe storage, handling and administration of medicines. Shirebrook Priory DS0000070803.V355020.R01.S.doc Version 5.2 Page 18 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): 22 and 23 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Not all residents are helped to express their views and staff would not know how to safeguard a resident if they were at risk of abuse. EVIDENCE: There is a complaints procedure, but there is not a complaints book to record any complaints in. The acting manager said there have not been any complaints made and this was also stated on the Annual Quality Assurance Assessment. Staff said they knew about the complaints procedure, but were not aware of any complaints. Staff said they did not know how residents with restricted speech would be able to make a complaint. A resident told the expert by experience that the staff were good with complaints. The acting manager was spoken with by telephone after this visit to check whether any complaints have been received. The acting manager confirmed that there have not but would remind staff in a staff meeting that all complaints must be recorded in line with the home’s complaints procedure. The acting manager said they have not yet got a copy of the new Adult Protection (Safe Guarding) procedures, but that the provider will be training Shirebrook Priory DS0000070803.V355020.R01.S.doc Version 5.2 Page 19 the managers of their homes in these who will then pass this on to staff. The acting manager said this will be done in a staff meeting. Staff said they had not had any training on safeguarding adults and did not know about the (Safe Guarding) Adult Protection procedures or the whistleblowing policy. The expert by experience said staff made him lock the arts and craft room when he was not using the room to talk to residents in private. This was because they were aware that there was scissors in the room. They were aware of health and safety or the risks involved with this. Shirebrook Priory DS0000070803.V355020.R01.S.doc Version 5.2 Page 20 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): 24 and 30 People who use the 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 home is not in a suitable condition due to a lack of maintenance and decoration for residents to live in. EVIDENCE: The acting manager and operations manager spoke of plans to carry out a major refurbishment on the home and said there are a number of problems with the condition of the building including the roof and rising damp. The operations manager said that since taking over the home the provider has had to carry out some emergency repairs, including ones to the heating and wiring. The expert by experience said the general condition of Shirebrook Priory looked a little neglected. The walls showed signs of damp. Outside windowsills were broken and rotten. Shirebrook Priory DS0000070803.V355020.R01.S.doc Version 5.2 Page 21 A resident told the expert by experience he liked the colour of his room, “it’s blue my favourite colour” but another resident said, “My favourite colour is yellow, and my room is white.” The acting manager said she was in the process of recruiting a cleaner who is due to start early in the New Year. Staff have not had training in infection control. Shirebrook Priory DS0000070803.V355020.R01.S.doc Version 5.2 Page 22 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): 32, 34 and 35 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels are not determined by an assessment of residents’ needs and residents are not protected by the home’s recruitment practices EVIDENCE: The acting manager said there is not a written assessment as to what the staffing levels should be, but current arrangements are there are four staff on a long shift each day from 8 am until 8 pm then 2 night staff until the following morning. The acting manager said it had been difficult to cover some shifts recently due to a number of staff leaving following the change of ownership of the home. A resident said to the expert by experience “I like it here, I wouldn’t change a thing, I like the staff”. Another resident said, “I want to get out and about, but there is not enough staff.” There was one new member of staff starting work today, however when checking her employment file it transpired that she has not had her Criminal Shirebrook Priory DS0000070803.V355020.R01.S.doc Version 5.2 Page 23 Records Bureau or Protection of Vulnerable Adults check returned. The operations manager made arrangements for her not to attend the home until one these have been received. The acting manager said she was working on compiling a training programme and manual handling and restraint training have both been booked. The operations manager said a review is being carried out about the current arrangements for staff working towards National Vocational Qualifications and what changes may need to be made to these. Shirebrook Priory DS0000070803.V355020.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): 37, 39 and 42 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are shortfalls in the management arrangements for the home, which are being attended to by the new providers. EVIDENCE: The acting manager has started the process of applying to become the registered manager and is currently waiting for her Criminal Records Bureau check to be returned. The acting manager has completed National Vocational Qualification level 4. Staff said they think the changes planned are going to be good, the new acting manager is sorting things out and the residents seem much happier. Shirebrook Priory DS0000070803.V355020.R01.S.doc Version 5.2 Page 25 The new provider took over the home in October 2007 and the operations manager highlighted in the Annual Quality Assurance Assessment a number of areas that are planned for improvement over the next 12 months. The operations manager is carrying out regular inspections of the home as required by Regulation 26 Care Homes Regulations 2001. The operations manager said there is currently some work being undertaken to produce questionnaires for residents and relatives to complete to comment upon the services provided. It was stated in the Annual Quality Assurance Assessment that Shirebrook Care Group is piloting a new service user questionnare which they intend to role out to all its services in the near future. The Annual Quality Assurance Assessment showed that some of the essential health and safety checks have not been carried out at the required frequency and these need attending to. Shirebrook Priory DS0000070803.V355020.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 1 2 1 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 1 33 X 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 X LIFESTYLES Standard No Score 11 X 12 1 13 2 14 X 15 3 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 3 1 X 3 X 3 X X 2 X Shirebrook Priory DS0000070803.V355020.R01.S.doc Version 5.2 Page 27 N/A 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 YA1 Regulation 4(1) Requirement The Statement of Purpose must be kept up to date and accurately reflect the services provided in the home There must be arrangements in place, which are known by staff, to assess the needs of any prospective new resident so they are properly assessed Each resident must have an up to date care plan that clearly describes how his or her assessed needs are to be met and should be drawn up with the involvement of the resident and kept under regular review. Residents must be provided with greater opportunities to make decisions about their lives and suitable communication aids should be used to assist with this. There must be a robust system for assessing any potential risks faced by residents which staff must be familiar with. More frequent and varied activities must be provided, including involvement the local community. DS0000070803.V355020.R01.S.doc Timescale for action 01/03/08 2 YA2 14(1)(a) 01/02/08 3 YA6 15(1) 01/03/08 4 YA7 12(3) 01/03/08 5 YA9 13(4) 01/02/08 6 YA12 YA13 16(2)(n) 01/03/08 Shirebrook Priory Version 5.2 Page 28 7 YA17 16 (2)(i) 8 YA18 12(4)(a) 9 YA20 13(2) 10 YA20 13(2) 11 YA22 17 (2) 12 YA22 22 (2) A review of the current catering arrangements should be held to ensure that residents are provided with a balanced, varied and wholesome diet. Personal support must be provided in a manner that promotes residents’ abilities and independence. The home must have a procedure for the safe administration of medicines, which must be followed by staff. When it is necessary to handwrite a Medicine Administration Record this must be signed by the person doing so and by another person to confirm they have checked it has been copied correctly. A record must be made of any complaint, which includes any investigation and outcome of the complaint. . All residents must be able to access the complaints procedure. This will ensure that all residents are able to make a complaint. All staff must be familiar with the procedures to follow to safeguard residents if there is any suspicion of abuse. The physical standard and cleanliness of the home must be improved so that residents live in a homely, comfortable and safe environment. There must be a review of the current staffing arrangements to ensure that there are sufficient staff suitably deployed to meet the needs of the residents. The correct recruitment process must be followed at all times, including obtaining a Criminal Records Bureau or Protection of Vulnerable Adults check. DS0000070803.V355020.R01.S.doc 01/04/08 01/03/08 01/02/08 01/01/08 01/02/08 01/03/08 13 YA23 12 (1)(a) 01/02/08 14 YA24 YA26 23(2)(b) 01/09/08 15 YA32 18 (1)(a) 01/02/08 16 YA34 19 (1)(a) 01/01/08 Shirebrook Priory Version 5.2 Page 29 17 YA35 18(1)(c) (i) 12(1)(a) 18 YA42 All staff should receive the 01/04/08 training they require to be able to meet the needs of the residents. All the required health and safety 01/02/08 checks and tests must be carried out within the required timescale to promote the safety of residents. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Shirebrook Priory DS0000070803.V355020.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Priory DS0000070803.V355020.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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