Inspection on 06/05/08 for Shirebrook Priory

This inspection was carried out on 6th May 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 7 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 03/12/07

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 28/09/2008.

CARE HOME ADULTS 18-65 Shirebrook Priory Retford Road South Leverton Nr Retford Nottinghamshire DN22 0BY Lead Inspector Stephen Benson Unannounced Inspection 6th May 2008 09:30 Shirebrook Priory DS0000070803.V363956.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.V363956.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.V363956.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) shirebrookpriory@shirebrookcaregroup.co.uk Mrs Sharon Radford Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Shirebrook Priory DS0000070803.V363956.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. 3rd December 2007 Date of last inspection 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.V363956.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 1 star. This means the people who use this service experience adequate quality outcomes. This was the first visit to the home since 1st April 2008 by The Commission for Social Care Inspection. Prior to the visit an analysis of the home was undertaken from information gathered over the last year 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 5 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. Other residents were spoken with and additional records were seen. A discussion was had with the acting and operations managers, 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. One survey form sent to the home by The Commission for Social Care Inspection had been completed. What the service does well: What has improved since the last inspection? Shirebrook Priory DS0000070803.V363956.R01.S.doc Version 5.2 Page 6 A new Statement of Purpose has been prepared. Residents are now provided with greater opportunities to make decisions about their lives although there are still not suitable communication aids to assist with this. There is now a system in place for assessing potential risks. Personal support is provided in a manner that promotes residents’ abilities and independence. Staff are familiar with the procedures to follow to safeguard residents if there is any suspicion of abuse. The cleanliness of the home has improved. The correct recruitment process are now followed, including obtaining a Criminal Records Bureau or Protection of Vulnerable Adults check. There is a staff training programme to so staff can meet the needs of residents and the majority of staff have or are working towards a professional qualification. All the required health and safety checks and tests are carried out within the required timescale to promote the safety of residents. Staff felt the changes made to the management of the home are an improvement. What they could do better: 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. Details of residents’ ethnic origin and information about any significant relationships must be included in the care plan. There must be a system in place to monitor any particular health condition and information must be available about how staff must respond. The reasons for any change in medication given must be recorded on the Medicine Administration Record. Arrangements must be made for medication to be administered at the correct time. Shirebrook Priory DS0000070803.V363956.R01.S.doc Version 5.2 Page 7 The physical standard of the home must be improved so that residents live in a homely, comfortable and safe environment Appropriate responses must be made to maintenance issues that present a health and safety risk. Residents must have opportunities to express their views on how the home is run. This will ensure that residents can have a say in the running of the home. 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.V363956.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 Priory DS0000070803.V363956.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): 1 and 2 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. Information can now be made available to those using or have interests in the service about the services provided. EVIDENCE: The acting manager said the responsible individual was preparing the new Statement of Purpose, but she had not yet received a copy of this. The acting manager contacted the responsible individual who faxed a copy to the home. Information provided on The Annual Quality Assurance Assessment (AQAA) stated that there have not been any people admitted to the home in the last 12 months. The acting manager said there have not been any admissions to the home since the change of ownership. The acting manager said that a decision has been taken by senior managers that there will not be any admissions to the home until the refurbishments have been carried out. The work on developing the home’s admission procedure has therefore been put on hold to allow for other priorities to be Shirebrook Priory DS0000070803.V363956.R01.S.doc Version 5.2 Page 10 addressed. With this in mind a requirement has not been set for standard 2 although the standard is not met. Shirebrook Priory DS0000070803.V363956.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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care files are improving. Residents are supported to make decisions about their lives and to take appropriate risks. EVIDENCE: There was a requirement set at the last visit that 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. Following that visit the home was required to submit an improvement plan, which stated that this requirement would be complied with by 31st July 2008. A sample of three care files were looked at. One had been rewritten and provided clear description of what assistance is required and by whom. For example one entry stated ‘eats independently but requires assistance of 1 carer to cut some foods up’. Shirebrook Priory DS0000070803.V363956.R01.S.doc Version 5.2 Page 12 The personal profile does not include any reference to a resident’s ethnic origin, sexuality or details of any significant relationship they have had. There was a system in the care plan for them to be updated, but this had not been used. Another plan had not been started to be updated and the third was in progress of being done. The acting manager said she had written to relatives asking them to provide details about their relative to help with the compiling of care plans. The acting manager said she was working to the timescale of the end of July 2008 to have all the care files up to date. It was stated on the AQAA that it is planned to continue to develop care plans to ensure residents, their families, friends, advocates and key stakeholders views are incorporated The requirement is therefore repeated in this report with the same completion time. Staff said they had discussed one plan with a resident who appeared to get a lot out of it. There were references seen in the rewritten care plan to the resident being able to make choices about certain things. Staff were seen encouraging residents to make decisions about everyday matters, for example asking a resident where they wanted to sit at lunchtime. Another resident was seen asking for a second cup of tea, which he was given. The acting manager said that the promotion of residents making decisions had been addressed through staff training and observing practice. The acting manager said she questioned staff when they did not appear to be encouraging residents to make decisions. Staff said that residents make decisions about their lives that they are able to. This includes things like when to have a drink, what activities they want to do and the clothes they wear. One resident was seen choosing to lie out in the sun on a sun lounger and others using different areas of the home. The daily notes showed that residents get up at differing times and one resident regularly gets up in the early hours. Shirebrook Priory DS0000070803.V363956.R01.S.doc Version 5.2 Page 13 There were risk assessments seen in care plans including ones for moving and handling, falls prevention, nutrition, continence and tissue viability. The acting manager said that daily risk assessments are carried out for residents going out on activities to assess whether they are in the right frame of mind that day. Staff said they try to encourage residents to take risks as this is part of everyday fulfilling lives, as long as we assess whether they are able to do so, for example making themselves a cup of tea or making cakes. Shirebrook Priory DS0000070803.V363956.R01.S.doc Version 5.2 Page 14 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are able to take part in appropriate activities and maintain family relationships. Residents’ rights are respected and they enjoy their meals. EVIDENCE: It was stated on the AQAA that the home aims for residents to have access to a wide range differing leisure activities and occupational activiteis based on their individual choices and preferences. There was an arts and crafts session taking place with three residents being supported by two staff. This was well run by the staff who motivated the residents well. Two residents completed colouring pictures and one was encouraged to write his name on his. The resident was asked if he liked the picture and he replied, “Yes”. Shirebrook Priory DS0000070803.V363956.R01.S.doc Version 5.2 Page 15 Another was seen singing along to some songs with a member of staff. The resident was smiling and clapping. The acting manager said that she had given staff guidance on how to get things out of sessions with residents and that the programmes of activities are organised within the home. The home has one mini bus to take residents out, however this causes problems when, as happened today, a resident had to attend a medical appointment rearranged at short notice, resulting in other residents being restricted to activities in and around the home. Two residents were seen having an early lunch and one said, “I am going to Retford this afternoon”. There were a number of references seen in care files to contact with families and staff said one resident had just been to visit a family member in his home area for the first time in 20 years as his family were no longer able to travel to him. The acting manager said that there has been a lot of work going on to promote contact where it was not occurring regularly. Two relatives came to visit a resident and said they come every week. A resident said, “Mum and Dad will come and take me home on Saturday”. It was stated on the AQAA that residents have been given greater choice in decision making about their day to day lives. Staff said that they ask residents in the mornings if they want to get up, they usually do but can have a lie in if they want to. A resident said, “I choose things” and another resident said when asked what was he going to do in the afternoon said, “Watch Home and Away in my room”. The home has a 4 week rolling menu which provides a choice of dish at every meal. Staff complete a form with residents the previous day of what they would like to eat the following day. The main meal is at lunchtime and dishes include lasagne, chicken and mushroom pie, liver or sausage and spaghetti bolognaise. There is a fish dish weekly and a roast dinner on Sundays. A lighter meal is had at tea time with such things as corned beef hash, choice of topping on toast, omelettes and macaroni cheese. A pudding is provided at lunch and teatime. Shirebrook Priory DS0000070803.V363956.R01.S.doc Version 5.2 Page 16 Lunch today on the menu was a choice of gammon steak with pineapple or egg or pork steak, roast potatoes and cauliflower, followed by rice pudding. The choice form had not been completed the previous day and the cook was preparing gammon steaks for all. When served there was not any pineapple or egg and the meal was served with thick gravy. Residents were seen eating their lunch and one resident said, “I don’t want potatoes”. Staff took the meal away and reserved it without them. Staff were seen assisting some residents to cut up their meals, one resident said he wanted to do it himself, so was left to do so, but staff made further offers to which he eventually accepted assistance. When asked if they had enjoyed their meal residents replied “Yes”. Shirebrook Priory DS0000070803.V363956.R01.S.doc Version 5.2 Page 17 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents receive personal support in an appropriate way, but the systems for meeting their health needs are not sufficiently robust. EVIDENCE: The acting manager said that personal support has been discussed within staff meetings and she has pushed the issue of promoting the privacy and dignity of residents. During the visit one resident was seen walk into the lounge partly undressed. A member of staff promptly responded and took the resident to his room to get dressed. Staff said that they provide whatever assistance is needed; some need a lot more than others. Staff said they try to get residents to do as much for themselves as they can; it is more a question of helping residents to do things rather than doing them for them. Shirebrook Priory DS0000070803.V363956.R01.S.doc Version 5.2 Page 18 A resident said, “Staff do things for me when I can’t”. Two of the care files seen had health action plans and the acting manager said that these are used to oversee and monitor residents’ health. It was stated on the AQAA that residents have individual care plans, which include moving and handling assessments, risk assessments, weight monitoiring and nutrional screenings, physical health and care needs. The daily notes showed that one resident had recently had two seizures. The person concerned had not got an updated care file and did not have a health action plan. There was not a care plan seen for the resident in case of a seizure and staff said they had not seen one. The daily notes showed a doctor had been contacted and a change to medication authorised. The extra dosage was recorded on the Medicine Administratioin Record but the reason for doing so had not been entered on the back. It was recorded in one health action plan that one resident refused to be seen by the chiropodist. The acting manager said that staff monitor the conditon of the resident’s feet. The acting manager said that she had recently written to residents’ families about using a dental service that will visit the home. Staff were seen putting sun cream onto residents who were outside due to the fine weather. A resident said, “I haven’t been very well recently, I’ve been having a rest” and “I saw the psychiatrist last week, who had a talk with me”. A team leader was seen giving out some of the morning medication, who said the medication was being given out late as she had been to the doctors. Medication was being administered correctly and signed for on the Medicine Administration Record once the resident had been seen to take it. The acting manager said that she had changed the system for storing medication to a monitored dosage system. The acting manager said that senior staff give out medication and thee is a senior on at night time. A resident was seen drinking some liquid medicine and giving the empty pot back to staff saying, “There all gone”. Shirebrook Priory DS0000070803.V363956.R01.S.doc Version 5.2 Page 19 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are systems in place for residents to raise complaints and protect residents from abuse. EVIDENCE: The home has a complaints procedure and a book to record any complaint in. There were no entries made in the complaints book. Information provided on The AQAA showed that there have not been any complaints made since the change of ownership of the home. Staff said they have seen the complaints procedure and a copy is displayed on the staff room wall. One resident was seen complaining to staff that his sun hat had gone missing. Staff provided another one while they searched for it. This was found a short while afterwards. Staff said they will record this in the complaints book. The resident said, “My hat was not where I left it”. Information provided on The AQAA showed that there has been 1 safeguarding referral made and 1 safeguarding investigation has taken place. There have not been any referrals made to the Protection of Vulnerable Adults list. Shirebrook Priory DS0000070803.V363956.R01.S.doc Version 5.2 Page 20 The acting manager said that this investigation was still being carried out. The acting manager said that there had been training on safeguarding adults provided recently and issues of safeguarding are discussed in staff meetings. The acting manager said she had raised with staff to take care so that thing could not be misconstrued. Staff were able to demonstrate an understanding of safeguarding and said they had recently attended safeguarding training. Staff said they knew a phone number to call if they needed to whistle blow. Two residents were able to answer questions asked about whether they felt safe in the home an d both said that they did. Both residents said they would tell a member of staff if they felt frightened. Staff said they keep an eye out for any bumps and bruises and if any seen try to find out where they came from. Shirebrook Priory DS0000070803.V363956.R01.S.doc Version 5.2 Page 21 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. Residents quality of life would be enhanced if the physical standards of the home were improved. EVIDENCE: The building is in a poor state of repair and décor. The providers knew this when they purchased the building and an architect is drawing up some plans for a major refurbishment, which is planned for later this year. The dining room has been decorated and new tables and chairs provided. It was stated on the AQAA ‘Clearly the environment at Shirebrook Priory requires substantial investment, SCG (Shirebrook Care Group) is developing plans to improve the environment at Shirebrook Priory’. Any repairs are reported to a 24-hour maintenance team. Shirebrook Priory DS0000070803.V363956.R01.S.doc Version 5.2 Page 22 There was a sharp hazard by the front door, which posed a risk to anyone who caught their hand on it. This had not been passed to the maintenance team. When bought to the attention of the acting manager she made temporary arrangements to make it safe and arranged for someone from the maintenance team to remove it later in the day. The operations manager said they provide a prompt response to emergencies, such as a cooker not working, and maybe need to look at responses to health and safety issues. Staff said the garden area is a big plus and that they have seen another home refurbished by the provider and it would be good if the home was risen to those standards. A resident said, “I like to go into my room, its away from the noise”. The home has now employed a cleaner who was seen cleaning various areas of the home. The acting manager said staff have been provided with infection control training. Information provided on The AQAA stated that there is a policy at the home for preventing infection and managing infection control and that 4 staff have received training on the prevention of infection and management of infection control. It was stated in the AQAA that a deep cleaning exercise, especially in residents’ rooms, has been undertaken. Staff were seen using protective clothing when serving dinner and when applying sun cream. Staff said they have plenty of protective clothing available. Shirebrook Priory DS0000070803.V363956.R01.S.doc Version 5.2 Page 23 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are supported by competent and qualified staff and supported and protected by the home’s recruitment policy and practices. Residents individual and joint needs are met by appropriately trained staff. EVIDENCE: Information provided on The AQAA showed that there are 13 care staff and a further 2 support staff employed. Two care staff have left the home in the last 12 months. There have not been any shifts covered by agency staff in the past three months. It also stated that the home employs male and female staff and they are of varying ages. The manager has assessed the minimum staffing levels to be 5 care staff during the day and 3 care staff at night. In addition the home employs a cook and a cleaner. Shirebrook Priory DS0000070803.V363956.R01.S.doc Version 5.2 Page 24 Residents were seen getting individual attention from staff who said they felt there were enough people on duty. A sample of three staff files were looked at and these showed the correct recruitment checks were carried out. Three staff spoken with confirmed that they had a Criminal Records Bureau check and character references taken up before they started work in the home. Information provided on The AQAA showed that there are 6 care staff who have National Vocational Qualification level 2 or above and a further 7 working towards one of these. The acting manager said that two staff have attended training on equity and diversity which they are planning to share with the remainder of the staff. The acting manager showed a training file, which showed details of recent courses. These included basic food hygiene, infection control, moving and handling, safeguarding adults and restraint and breakaway. Staff said there has been a lot of training provided recently. Shirebrook Priory DS0000070803.V363956.R01.S.doc Version 5.2 Page 25 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management systems are being put into place for the smooth running of the home and ways of increasing residents voice are being established. EVIDENCE: The acting manager has submitted an application to us to be considered to become the registered manager. The acting manager is currently working towards the registered managers award. Staff said that there has been more training and staff meetings but maintained the things that residents liked. Staff said they thought the home was moving forward. Shirebrook Priory DS0000070803.V363956.R01.S.doc Version 5.2 Page 26 The operations manager said that Regulation 26 visits are undertaken and it was stated on the AQAA that Regulation 26 visits take place on a monthly basis by the Group Care Manager or Operations Manager. The acting manager has not yet implemented a system of seeking residents and relatives views other than for compiling care plans but would be doing so in due course. The acting manager said that all the required health and safety checks are carried out at the required frequency and there are service contracts in place for servicing all the equipment. It was stated on the AQAA that the premises electrical circuits and portable electrical equipment have not been tested as recommended by the manufacturers or other regulatory body. The acting manager confirmed that these have recently been done and they have the certificates. It was also stated that there are written assessments on hazardous substances. Shirebrook Priory DS0000070803.V363956.R01.S.doc Version 5.2 Page 27 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 3 2 3 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 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 2 X X 3 X Shirebrook Priory DS0000070803.V363956.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes (but timescales not yet expired) 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(1) Requirement 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. Details of residents’ ethnic origin and information about any significant relationships must be included in the care plan. There must be a system in place to monitor any particular health condition and information must be available about how staff must respond. The reasons for any change in medication given must be recorded on the Medicine Administration Record. The physical standard of the home must be improved so that residents live in a homely, comfortable and safe environment. Appropriate responses must be made to maintenance issues that present a health and safety risk. DS0000070803.V363956.R01.S.doc Timescale for action 31/07/08 2 YA6 15(1) 31/07/08 3. YA19 12 (1)(a) 01/06/08 4 YA20 13(2) 12/05/08 5. YA24 23(2)(b) 01/09/08 6 YA24 23(2)(b) 12/05/08 Shirebrook Priory Version 5.2 Page 29 7 YA39 24 (1)(a) Residents must have opportunities to express their views on how the home is run. This will ensure that residents can have a say in the running of the home. 01/07/08 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 Refer to Standard YA17 Good Practice Recommendations Ensure that residents have opportunities to choose their meals and that dishes include the trimmings described on the menu. Shirebrook Priory DS0000070803.V363956.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 Priory DS0000070803.V363956.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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