Inspection on 02/09/08 for Shirebrook Views

This inspection was carried out on 2nd September 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shirebrook Views 21/11/07

Shirebrook Views 05/03/07

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 13/11/2008.

CARE HOME ADULTS 18-65 Shirebrook Views 22 Wellington Street Matlock Derbyshire DE4 3JP Lead Inspector Nancy Bradley Unannounced Inspection 2nd September 2008 09:00 Shirebrook Views DS0000068253.V371238.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 Views DS0000068253.V371238.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 Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shirebrook Views Address 22 Wellington Street Matlock Derbyshire DE4 3JP 01629 55662 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Shirebrook Care Limited Manager post vacant Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Shirebrook Views DS0000068253.V371238.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: Learning disability - Code (LD) The maximum number of service users who can be accommodated is: 14 21st November 2007 2. Date of last inspection Brief Description of the Service: Shirebrook Views is a care home providing accommodation and personal care for eleven people with a learning disability. The accommodation is in a twostorey building, which has been adapted from a large house. There is a garden and a paved patio area with seating, and there are views over the town of Matlock and the surrounding area. Peoples ’ bedrooms are situated on the ground and second floors. There is a stair lift from the main entrance level to the ground floor. The home is not equipped with a lift and as such, the second floor accommodation is not suitable for people with significant mobility difficulties. The ground floor has two shared bedrooms, a single bedroom and a bathroom. The second floor has six single bedrooms, a bathroom and a separate toilet. The previous inspection report is on display in the entrance area of the home. The manager did not have information on current fees as this is dealt with by head office. Shirebrook Views DS0000068253.V371238.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 an unannounced key inspection and took place over a total of six hours. An Expert by Experience accompanied us and they were present for three hours of the site visit. We spoke with the people living at the home, manager and care staff. 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. As shown in the management section the AQAA provided little information about the home. Two people living at the home were case tracked. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at 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. We joined people from the home for lunch. There were ten people living at the home on the day of the visit, although they are registered for fourteen. The questionnaires were completed with the help of care workers and indicated that they are happy at the home. Several of the people indicate they did not understand the questions with the majority of the answers being ticks. We received four completed questionnaires from staff who indicated they were happy working at the home and found the new manager supportive and always makes time to discuss issues. We have received no questionnaires from relatives. What the service does well: Shirebrook Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 6 The Expert by Experience stated the atmosphere in the home was good. Care staff were very friendly to people living at the home and responded to and supported them. Especially to the people who have limited verbal communication skills. The Expert by Experience stated the meals and food offered to people at the home were good. Several of the people are very independent and the home encourages their independent life style. This is being developed further with the implementation of more life skills into the care plan. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. 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 Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 7 • 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 Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 8 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): Standard 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that peoples’ needs are fully assessed prior to admission and are reviewed at regularly. This will ensure that peoples holistic needs will be appropriately met. EVIDENCE: There have not been any people admitted to the care home since the last site visit. Therefore, all of the original assessments pre-date the current management arrangements. Shirebrook Care is looking to re assess all of the people living at the home as their care needs are changing. The majority of the people living at the home have been there for a number of years. There was a change of ownership in 2006. There was evidence on file to show that the care needs assessments for people are being reviewed by the referring agency. Several of the people spoke with recalled coming to have a look around the home before coming to live there. The home has four vacancies at the time of this site visit. This inspection had been brought forward from its scheduled dated of November 2008 due to safeguarding and care issues. Shirebrook Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 9 Following the meeting with referring agencies contracts were suspended in April 2008. The responsible individual reported that following a meeting with referring agencies the day before contracts had been lifted. This has yet to be confirmed. Shirebrook Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 10 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): Standard 6,7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Inconsistencies in the care planning system and recording may compromise service delivery. EVIDENCE: During the site visit care plans of two people living at the home were viewed. The manager is compiling the care plans for each person who lives at the home and evidence there was evidence of being evaluated monthly. There was evidence of care plans being formally reviewed on a six monthly basis. Discussions with people living at the home confirmed they knew about their care plan and were involved in the process. The care plans used are the Shirebrook Group Care corporate documentation, which are based on a nursing model rather than a social care model. The manager is looking to implement new care planning, risk assessments and individual profiles on all people at living at the home. During the site visit we were able to examine one of the new style care plans. Care plans will be person-centred with an easy read format for people to understand. Daily living Shirebrook Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 11 notes will be completed on each person by the staff on duty. This will include night staff as well. The manager stated the implementation of the new care plans would be given priority. The home maintains daily and night records on all people at the home. Peoples are now being involved more in the care planning process and this needs to be extended to include family, friends and/or advocates, and/or other relevant agencies. Care plans were being signed by people .as evidence of their participation in the decision making process. The manager stated she would like to see the Advocacy Service involved more in the home and care planning is a way this could be achieved. . All paperwork was signed and dated by the home. Risk assessments were in place, these need 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 service users’ records, for example tissue viability, trips and activities. These need to be updated and reviewed in line with care plans. Shirebrook Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,15 16 and 17. Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. There were arrangements in place to enable people at the home 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: The majority of the people who live at the home attend the local day centre between three and four days a week and transport is provided. There are some other occupational type activities available for people who do not wish to attend the centre. Comments from people at the home stated they like to watch TV, have relatives visit and go out shopping. Staff reported that families tend to visit more at weekends. People living at the home confirmed their relatives are always made welcome. The minister visits the home monthly for people wishing to take part in religious services. Shirebrook Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 13 Information on records indicate that contact with family and friends were appropriate. The relationship observed between care staff and service users were open and friendly. The service users are encouraged to take pride in their appearance and their preferred style of dress is respected. The manager has implemented a more flexible daily routine for people at the home and they are now being supported to make their own decisions about how they spend the day. People spoken with by the Experts by Experience stated they could do anything they like in the home, for example they can sit out in the garden, and help to get their own meals. Examination of the menus and discussions with the care staff indicate the home is providing a healthy well-balanced and nutritious diet. People are given a choice of meals, fresh fruit and drinks are available. Care staff at the home prepare the meals, as the home has no cook. The menu is displayed and the manager has compiled an easy read format. We took lunch with the people living at the home and care staff were observed assisting people with their meal. The manger confirmed that all staff are having to complete a food hygiene course. An Environmental Health Officer made a routine visit to the home last year. Shirebrook Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19,20 and 21. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home should receive personal support in ways, which enables them to be independent and have control over their lives. EVIDENCE: Several of the people living at the home are not able to express themselves verbally and to directly contribute to the visit. During the tour of the home we spoke with some people who stated they were happy at the home, the staff cared for them and that they liked it there. The people who were less able to express themselves looked relaxed and contented. Direct observations identified that the majority of the people require some assistance with personal support with several having a high level of need and support. The home has started to look at identifying areas of need however the short falls in staffing have meant that this area is not always fully attainable. The shortfall resulted in poor care practice and referrals to Social Services Adult Departments under Safeguarding of Vulnerable Adults. At present only one person is accessing the Advocacy Service. The manager would like this extended to cover all of the people at the home. The manager Shirebrook Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 15 envisages advocates being involved in house meetings and care issues, which people may have. Several of the people stated that they were not happy about the proposed change and were finding it difficult to understand and cope with, having been there for such along time. People living there must have control over their own lives; they should be supported through any changes in a manner, which promotes their independence. Discussion with staff indicate that they have satisfactory insight into the needs of individual people and are committed to supporting and assisting them. It is important that there are up to date and detailed records on how peoples’ needs are addressed, and to safeguard them by ensuring that their total care needs are identified. The manager confirmed that annual medicals with the doctors are now taking place. The community nurse is involved and triggers when health checks are required. The manager is looking to implement health care plans into the overall person centred care planning. People were generally healthy and records showed that care staff promptly contacted the appropriate medical services. Records seen indicated that all of the people have been registered with the local doctor, optician, podiatry services, dentist, and audiologist. The home operates and monitors peoples’ medication, as none of them are able to do so. Although the manager stated that one person at the home could administer their own medication but chooses not to. The arrangements for receipt, storage, administration and disposal of medication were also examined and found to satisfactory. The AQAA indicated that only fully trained staff administers medication. Medication administration is recorded on Medication Administration Records (MAR sheets). The home has their medication supplied from Boots pharmacy and an audit of medication procedures by them has been undertaken. Currently the home only has prescribed medication. It was noted that the temperatures for the fridge used to store medication fluctuated and were not within a safe range. The manager agreed to address this. At present the people living at the home do not have an end of life plan. The manager realise that this is an area which needs to be addressed. Shirebrook Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to safeguard peoples’ welfare and ensure that their concerns are listened to and acted upon. However the lack of training in safeguarding may leave people vulnerable. EVIDENCE: Discussion with the Expert by Experience and from completed questionnaires confirmed that people were aware of the home’s complaints procedure. A copy of the home’s complaints procedure was not displayed in the home. The manager confirmed that the complaints procedure is being added to the Service Users Guide in an easy to read format. Any concerns and complaints made are investigated within the agreed time scales and in line with in Shirebrook Cares policy and procedures. The manager maintains a record of all complaints made by people details of the investigation action and outcome. The procedure contains the contact details of the Commission for Social Care Inspection in Sheffield and informs the complainants that they are able to contact us at any stage of the complaints process if they wish to do so. People told the Expert by Experience they would speak with the manager, staff or their families about any concerns they had. Records seen indicated that they had received no complaints since the previous site visit. We have not received any formal complaints about is service. Shirebrook Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 17 The home’s policy on Safeguarding Adults was examined. This is a corporate policy and has been updated to cover Safeguarding of Adults There have been a number of Safeguarding of Adults incidents since the last inspection involving the care people received whilst living at the home. Derbyshire Adult Services Departments have investigated these under their Safeguarding Adults procedures. As stated earlier in the report contracts have been suspended. Training records seen confirmed that training for all staff on safeguarding of adults is scheduled for later this month. At present only the manager has received training on safeguarding adults with several of the staff due for refresher training. The system for dealing with service users’ personal monies was discussed with the manager. There have been incidents were peoples money has been mislaid. A new system has now been set up and there have been no further incidents. The manager is solely responsible for people’s money and when she is not available a float is left. People indicated they were satisfied with this arrangement. Shirebrook Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The implementation of an improvement, plan would ensure the people live in a safe, comfortable and homely environment. EVIDENCE: We carried out a full tour of the home, accompanied by the manager. All communal areas were inspected together with staff facilities. Peoples’ bedrooms were inspected with their agreement and all rooms furnished to their personal choice and wishes. Shirebrook Views provides a domestic style environment for the ten people all of which have lived at the home for three or more years. Many of the rooms had been made in to bed-sit style accommodation, where service users can meet with family and friends in private. The issues relating to the environment and the general condition of the building have been identified in the previous two reports. The refurbishment of the building is urgently required. This has been discussed with representatives from Shirebrook Care Ltd, at the previous two site visits, and assurances were Shirebrook Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 19 given that this was going to be given priority. However they has been little or no new investment in the home since the last site visit. The general environment is dated and there were signs of wear and tear to furnishings and décor. Shirebrook Care Ltd have purchased new furniture for the general lounge. Completed questionnaires and discussions with people living at the home stated the home could be clearer. At present there is no cleaner working at the home and care staff are covering basic cleaning duties. There are still several area requiring attention from the pervious site visit. • • • • • • • Paintwork yellow, dirty and is peeing off in various parts of the home. Carpet dirty and thread bear in the upstairs landing. The majority of the carpets in the communal areas have seen better days and needs replacing or cleaning. Outside garden areas needs attention. Broken paving stones on the patio. General decoration of the house was dated. One person’s bedroom had an unpleasant odour. Furniture in the dinning room well worn and dated. There is s fishpond and at present is in accessible to people at the home. If this changes then the pond will need to be secured. The only refurbishment, which has been undertaken, is the residential accommodation that was occupied by the previous owner. This has been converted to make three more bedrooms and formed part of the variation to the homes registration. The standard of that accommodation is very good, however the rest of the home is not to that standard. This accommodation is not in full use. The laundry has been moved and is now situated in an outhouse to the side of the home. As discussed with the manager, clothes and bedding should not be left in there for any length of time, as the outhouse has open access and clothes may get damp. At present the there is no emergency call system fitted to the home. Risk assessments are in place, which address the lack of an emergency call system. Several of the rooms have been fitted with a mobile intercom system. The Expert by Experience stated the building needs completely renovating to make it more convenient and accessible for people who live there. Shirebrook Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,34,35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has robust recruitment and selection procedures in place to ensure that the appropriate staff are employed to care for vulnerable people. EVIDENCE: The home has a high percentage of staff who hold a NVQ level 2/3 or are working towards attainting the qualification. The home has a robust recruitment procedure in place, which ensures that their staff are suitable to work with vulnerable people. Several staff personnel records were examined which confirmed that thorough employment checks had been carried out. All new staff are required to provide two references, a full employment history, have a clear Criminal Records Bureau clearance and complete a three months probationary period. The records contained all required information has detailed in Schedule 2 of the National Minimum Standard, Care Homes for Adults 2001. The staff personnel records were well presented and organised. All staff receive induction training and commence comprehensive foundation training with three months of appointment. Shirebrook Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 21 Discussions with the manager and examination of training records indicate the home is providing good training and development opportunities. Details of staff training together with training planned were provided at the inspection. Training on the Mental Capacity Act, is planned. Discussions with the Manager and records examined confirmed that staff receive regular supervision. Shirebrook Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was generally well managed, with staff seeking the views of the people who live there. However the lack of affective quality assurance procedures may affect the overall running of the home. EVIDENCE: The home has not had a registered manager in post since Shirebrook Care Ltd took over the ownership of the home. The previous manager resigned her position in December of 2007 with the present manager commencing her duties in April 2008. The current manager is due to commence her Registered Managers Award and to submit her application for registered manager status to us. The Registered Provider has undertaken no formal quality assurance since the change of ownership. However the new manager is looking to seek the views Shirebrook Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 23 of the people living there by starting house meetings. The manager has an open door policy and is available to speak with family at any time. There have been no Regulation 26 visits within the last year. We were given the first one at this site visit. The AQAA dataset indicated that all the necessary maintenance of equipment checks had been undertaken. Environmental risk assessments were in place. Shirebrook Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 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 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 1 2 X 2 X X 3 X Shirebrook Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 25 YEs Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Comprehensive individual care plans must be developed for each person to demonstrate the assessed and changing care needs. This is to ensure that care staff are aware of people’s on going care needs. Individual plans of care must be drawn up with the involvement of the people living at the home, family/friends or advocate where appropriate. This is to ensure that they fully reflect the assessed needs of the people and they are involved in the decision making process. This is a previous requirement. Relevant risk assessments must be carried out and documented in people’s plan of care to promote the health and welfare of the resident. This is to ensure people are fully supported to take risk as part of an independent life style. This is a previous requirement. Timescale for action 31/10/08 2. YA6 15 31/10/08 3. YA9 17 31/10/08 Shirebrook Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 26 4. YA18 16 The home must consult with people living at the home about issues, which affect their health and welfare and in doing so take account of their wishes and feelings. This is to ensure that people living at the home have maximum control over issues, which affect their lives. This is previous requirement. The home must have in place an End of Life plan for all of the people who live there. This is to ensure that their wishes are respect and beliefs are met. The homes complaints procedure must be displayed and in a format which people living their can understand. This is to ensure people at the home can have their concerns acted upon and know how to make a compliant.. The compliant procedure must include the contact details for the local office of the Commission for social care. This is to ensure people know who they can make a complaint to. All staff must receive training on safeguarding of adults. This is to ensure people are fully protected. The home must ensure the premises are suitable for the aims and objectives as set out in the Statement of Purpose. This is to ensure people live in a homely and safe environment. This is a previous requirement The Registered Provider must implement the refurbishment of the home as soon as possible. This is to ensure that people in the home can assess all parts of DS0000068253.V371238.R01.S.doc 31/10/08 5. YA21 12 and 13 31/10/08 6. YA22 21 31/10/08 7. YA22 21 31/10/08 8. YA23 18 31/10/08 9. YA24 23 31/10/08 10 YA24 16 and 23 31/12/08 Shirebrook Views Version 5.2 Page 27 11. YA39 24 the home and live in a clean comfortable environment. The home must establish and maintain a system for reviewing the quality of care provided to service users. This is to ensure people who live at the home have a voice and are part of the reviewing and on going monitoring of the home. This is a previous requirement. Copies of the monthly provider visits must be sent to the Commission for Social Care Inspection until the end of the year. This is to ensure the effective and efficient running of the business and to promote an open, positive atmosphere and to demonstrate leadership and management of the home. 31/10/08 12 YA39 26 31/10/08 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. 2. Refer to Standard YA2 YA18 Good Practice Recommendations The additional three bedrooms in the short term should be used to facilitate the refurbishment. This is previous recommendation. All service users must be given the opportunity to access the services of an Advocate. This is a previous recommendation. The manager should submit her application for Registered Manager as soon as possible. 3. YA39 Shirebrook Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 28 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 Views DS0000068253.V371238.R01.S.doc Version 5.2 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!