Inspection on 21/11/07 for Shirebrook Views

This inspection was carried out on 21st November 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 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 22 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shirebrook Views 02/09/08

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 09/07/2008.

CARE HOME ADULTS 18-65 Shirebrook Views 22 Wellington Street Matlock Derbyshire DE4 3JP Lead Inspector Nancy Bradley ` Unannounced Inspection 21st November 2007 09:00 Shirebrook Views DS0000068253.V355324.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.V355324.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.V355324.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 Post Vacant Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Shirebrook Views DS0000068253.V355324.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 5th March 2007 2. Date of last inspection Brief Description of the Service: Shirebrook Views is a care home providing accommodation and personal care for eleven residents 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. Residents’ 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 residents 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. This is the first inspection report for this new service following a change in ownership towards the end of 2006. It was ascertained from the management at this inspection that the report would be made available in the entrance area of the home. The current range of fees is £333.70 - £389.60 per week excluding hairdressing, podiatry chiropody and toiletries. The manager confirmed these details at the time of the visit. Shirebrook Views DS0000068253.V355324.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection and took place over a total of six hours. The inspector spoke with the 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. There were eleven in the home on the day of the inspection; the home currently has vacancies for three service users. Additionally, time was spent in preparation for the visit, looking at the service history, and the previous inspection report. The Annual Quality Assurance Assessment questionnaire was not available at this inspection, as the questionnaire was not sent out in time for the inspection. Records were examined relating to the service users and the general running of the home. The Commission for Social Care Inspection sent out eleven “Have Your Say” questionnaires and all were returned. Services users confirmed they were happy at the home, were looked after by the staff, knew how to make a complaint and staff listened to what they wanted. Surveys for relatives and families were sent out and seven completed ones were returned, generally the comments from family members were satisfactory. Several family members stated that they thought the changes to the home were positive, however they should take account of the service users living there and their needs. The majority of the service users have been at the home for many years. The Homes Statement of Purpose, Service User Guide and complaints procedure were displayed in the main entrance to the home. What the service does well: Shirebrook Views is registered for service users with a learning disability and whilst it was not possible to obtain direct and detailed feedback from many of the service users it was clear from direct observation staff are caring and supportive in meeting their needs. Service users stated that the carers and manager are approachable and responsive to any issues that arise. All service user were happy to with their bedrooms and were pleased to have their personal belongs with them. Shirebrook Views DS0000068253.V355324.R01.S.doc Version 5.2 Page 6 The home provides a well-balanced and varied diet. The home has a caring and committed staff group. What has improved since the last inspection? What they could do better: There were some areas for improvement noted at this visit, the most important are summarised below. • • • • • • • There must be consistency in the style of service users care plans and method of recording used by the staff. A suitable programme of activities should be compiled by the home. The refurbishment of the home must take priority, as this is long overdue. The main body of this report contains details of the key shortfalls of the environment potentially affecting the service users. Service users should be consulted about the refurbishment and their views taken account off. All staff should receive regular supervision. The home must appoint a manager as soon as possible and submit an application to the Commission for Social Care Inspection for Registered Manager status The home must look at developing a system for assessing the quality of care provided to service users. • 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.V355324.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.V355324.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 service users’ needs are fully assessed prior to admission and are reviewed at regularly. This ensures that all potential service users holistic needs are appropriately met. EVIDENCE: There have not been any new service users admitted to the care home within the last three years. Therefore, all of the original assessments pre-date the current management arrangements following the change of ownership last year to Shirebrook Group Care Ltd. There was evidence on file to show that the care needs assessments for service users were are being reviewed by the referring agency. One service user confirmed that she did come to look around the home before coming to live there. The home has three vacancies following a variation to its registration from eleven to fourteen. Discussions took place at the inspection with the Operations Manager on how the home could utilise the beds rather than admitting new service users in the short term. The needs of the service users living at the home must be paramount and changes to the home must be at their pace and within their assessed needs. Shirebrook Views DS0000068253.V355324.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Inconsistencies in the care planning system and recording may compromise service delivery and leave service users vulnerable EVIDENCE: During the visit care plans of two service users were examined. The care staff for each service user have compiled the individual care plans and evidence was seen of care plans being evaluated monthly. There was no evidence of care plans being formally reviewed on a six monthly basis. 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 home has started to compile a life history for each service user, and is looking to follow a Personal Centre Planning approach. Some of the language used in the care plans and risk assessments was inappropriate. The home maintains daily and night records on all service users. As discussed with the manager the night record needs to have more detailed information recorded for each service user. Shirebrook Views DS0000068253.V355324.R01.S.doc Version 5.2 Page 10 The service user involvement in drawing up the plan should be through family, friends and/or advocates, and/or other relevant agencies. One service user had signed their care plan, however there was little evidence to show the service user’s part in the decision making process. Although care staff were observed encouraging service users to make decisions which affect their daily lives. 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.V355324.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported in making choices regarding their social and recreational life style, however service users would benefit from more occupational type activities. Service users enjoy a varied and balanced diet. EVIDENCE: Several of the service users attend the local day centre between three to four days a week and transport is provided. There are no other occupational type activities available to service users and the majority of their time is spent watching T V. Relatives’ surveys commented that there have been no trips out recently as the mini bus has broken down. However care staff do take service users out individually. The minister visits the home monthly for service users wishing to take part in religious services. Staff reported that families tend to visit more at weekends. Service users confirmed that their relatives are always made welcome at the home. Information on service users’ records indicated that contact with family and friends was appropriate. Shirebrook Views DS0000068253.V355324.R01.S.doc Version 5.2 Page 12 The relationships 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 service users and they are now being supported to make their own decisions about how they spend the day. Previously service users where given little or no opportunity of choice or freedom. From examination of the menus and in discussion with the care staff the home is providing a healthy well-balanced and nutritious diet. Service users are given a choice of meals and fresh fruit is available. The home is not large in terms of the number of service users or staff, and care staff prepares the meals. The menu is displayed and the manager is looking to compile a picture board menu. The inspector took lunch with the service users and staff were observed assisting service users with their meal. The manger confirmed that all staff are having completed a food hygiene course. An Environmental Health Officer made a routine visit to the home last year and there were no significant issues raised in regard to the catering at the home. Shirebrook Views DS0000068253.V355324.R01.S.doc Version 5.2 Page 13 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, and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users should receive personal support in ways, which enables them to be independent and have control over their lives. EVIDENCE: Several of the service users were not able to express themselves verbally and to directly contribute to the inspection. During the tour of the home the inspector spoke with several service users who said that the staff who looked after them cared for them and that they liked it at the home. Those service users who were less able to express themselves looked relaxed and contented. The direct observations identified that the majority of the service users require some assistance with personal support. Several of the service users have a high level of need and support. The home has started to look at the identifying areas of need however the short falls in staffing has meant that this area is not always fully attainable. Discussions with the manager confirmed that they have had staffing problems; this was also highlighted in surveys from relatives. At present only one service user is accessing the Advocacy Service. Several of the service users are finding the propped changes difficult to understand and to cope with, having been there for such along time. Service users must have control over their lives and changes to this must be recorded, Shirebrook Views DS0000068253.V355324.R01.S.doc Version 5.2 Page 14 explained to them and they must be supported in ways that promote their independence. Records examined did not support that this had happened, changes should benefit service users independence not hinder it. Discussion with staff indicate that they have satisfactory insight into the needs of individual residents and are committed to supporting and assisting them. It is important that there are up to date and detailed records on how service users’ needs are addressed, and to safeguard service users by ensuring that their total needs are identified and responded to. The manager confirmed that annual medicals with the doctors are now taking place. However there are still no clear assessed medical recognised procedures in place. The annual medical is triggered by the service user’s birthday. Discussion with the manager has to how this could be developed, was with each service users having his or her own health plan. Records examined and from discussions with staff, service users’ general health needs were being met Service users were generally healthy and records showed that staff promptly contacted the appropriate medical services. All service users have been registered with the local doctor optician, podiatry services, dentist, and audiologist. The home operates and monitors service users’ medication. None of the service users are able to administer their own medication. All staff have received training on medication training procedures. The arrangements for receipt, storage, administration and disposal of medication were also examined and found to satisfactory. However some liquid medication is being stored in the main homes refrigerator in the kitchen. This practice was discussed with the manager and the Registered Provider agreed to address this issue. Medication administration is recorded on Medication Administration Records (MAR sheets). The home has their medication supplied from the Boots and an audit of medication procedures by them is pending. Currently the home only has prescribed medication. Shirebrook Views DS0000068253.V355324.R01.S.doc Version 5.2 Page 15 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. There were suitable systems and arrangements in place to promote the safety of service users and staff. However the home’s current policy and procedures on protection leave service users and staff vulnerable and at risk. EVIDENCE: Service users are made aware of the home’s complaints procedure through the service user guide and via their key worker, a copy is also displayed in the home. The Manager has developed a user-friendly complaint form for service users. Any concerns and complaints made by service users are investigated within the agreed time scales. The Registered Manager maintains a record of all complaints made by service users, details of the investigation action and outcome. The procedure contains the current contact details of the Commission for Social Care Inspection and informs the complainants that they are able to contact the Commission at any stage of the complaints process if they wish to do so. Service users confirmed they would speak with the manager or their families about any concerns they had. Records seen indicated that one complaint had been received since the last inspection from a service users family member about their care. This had been addressed immediately by the home. Discussion with the service user confirmed that there where no further issues. The home’s policy on Safeguarding Adults was examined. This is a corporate policy and has been updated to cover Safeguarding of Adults. However the policy makes no reference to local procedures operated by Social Services, or Shirebrook Views DS0000068253.V355324.R01.S.doc Version 5.2 Page 16 to the Department of Health “No Secrets” documentation. The policy states that the following: • Managing Director or Group Care Manager will decide whether the alleged abuse might constitute criminal action, which will involve reporting to the matter to the police and taking guidance from them as to the timing and conduct of any internal investigation, which may proceed alongside police action. The policy and procedure needs to be amended to reflect Social Services Department as the lead in Safeguarding of Adults and referrals must be made to them for their consideration under the Departments procedures. Staff training records examined confirmed that staff had completed training on vulnerable adults in 2006. There has been no reported incident of Safeguarding of Adults since the last inspection. The system for dealing with service users’ personal monies was discussed with the manager. The Commission for Social Care Inspection had received a notification in April relating to service users monies being mislaid. A new system has now been set up and there have been no further incidents. The manager is solely responsible for services monies. Service users appeared to be satisfied with this system. Shirebrook Views DS0000068253.V355324.R01.S.doc Version 5.2 Page 17 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 25,27 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 and refurbishment plan would ensure the service users live in a safe, comfortable and homely environment. EVIDENCE: The Inspector carried out a full tour of the home, accompanied by the Manager and Operations Manager. All communal areas were inspected together with staff facilities. Service users’ 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 eleven service users, 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 report. The refurbishment of the building is urgently required. This was discussed at the inspection with representatives from Shirebrook Care Ltd, and an assurance were given that this is being given priority. However they has been little or no new investment in the home since the last inspection. The general environment is beginning to look dated and there were signs of wear and tear to furnishings and décor. Shirebrook Views DS0000068253.V355324.R01.S.doc Version 5.2 Page 18 The Operations Manger confirmed that he had recorded a similar statement in the last Regulation 26 visit. The following areas where identified as needing attention in order to meet the National Minimum Standards for Younger Adults. • Condensation to windows in service users’ bedrooms and communal areas. Several windows had blown and the black gasket to the window in the dinning room was hanging down. • Paint work yellow and had peeled off in the main hallway. • Carpet dirty and thread bear in the main hallway and is some areas was secured with tape. The majority of the carpets in the communal areas have seen better days. • Furniture in communal areas old and well worn. • Outside garden areas needs attention • Radiators in one part of the house where the laundry used to be were rusty, and the grouting in the tiles was dirty. • Linen cupboard not fit for purpose. • Upstairs bathroom, new flooring required. • Several of the bedrooms look out on to the street, and are overlooked from the house nearby compromising service users privacy. This needs to be addressed. • One window did allow access to the house where service users personal belongings were on view. • The light fitting in the dinning room was lose from its fitting and keeps blowing light bulbs. The Registered Provider agreed to address this immediately. • General decoration of the house was dated. • One double female bedroom no privacy curtain was fitted. 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 recent registration. The standard of that accommodation is very good, however the rest of the home is not to that standard. The laundry has been moved following the last inspection 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. Also several of the rooms have been fitted with a mobile intercom system. Although the home has implemented hygiene procedures, there was a strong smell when entering the home via the back door. Shirebrook Views DS0000068253.V355324.R01.S.doc Version 5.2 Page 19 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.V355324.R01.S.doc Version 5.2 Page 20 Discussions with the Manager and examination of records indicate the home is providing good training and development opportunities. Details of staff training together with training planned were provided at the inspection. The training programme however did not cover the Mental Capacity Act, which became law in April 2007. Discussions with the Manager and records examined confirmed that staff supervision did not meet the National Minimum Standards 36.4. Shirebrook Views DS0000068253.V355324.R01.S.doc Version 5.2 Page 21 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 must have quality assurance system in place, to ensure that service users have a voice and their views are listened to. EVIDENCE: The manager has resigned her position and leaves the home on the 4th December 2007. The Operations Manager will be providing management support until a new manager is appointed. The home has not had a registered manager in post since Shirebrook Group Care Ltd took over the ownership of the home. The Registered Provider has undertaken no formal quality assurance since the change of ownership, but the views of the service users are sought on a oneto-one basis on a regular basis. The manager has an open door policy and is available to speak with family at any time. The Registered Provider undertakes Regulation 26 visits and checks quality and performance matters on a monthly Shirebrook Views DS0000068253.V355324.R01.S.doc Version 5.2 Page 22 basis. The manager also provides monthly reports to the Registered Provider on an audit of medicines, accidents/incidents and complaints. There was no evidence of a risk assessment by a competent person to identify if any specific Legion Ella prevention measures are appropriate at the care home. The Registered Provider agreed to address this immediately. A sample of other maintenance documentation was examined and there was evidence of appropriate checking/maintenance of the main services at the home e.g. gas and electrical services. Environmental risk assessments have been put in place following the last inspection. Shirebrook Views DS0000068253.V355324.R01.S.doc Version 5.2 Page 23 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 3 23 2 ENVIRONMENT Standard No Score 24 1 25 2 26 X 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 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 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 2 X 2 X X 2 X Shirebrook Views DS0000068253.V355324.R01.S.doc Version 5.2 Page 24 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(1) Requirement Comprehensive individual plans of care must be developed for each service user to demonstrate that assessed and changing care needs are being reviewed and addressed. This is a previous requirement. Individual plans of care must be drawn up with the involvement of the service user, family or advocate where appropriate so that they fully reflect the assessed needs of the resident. This is a previous requirement. Relevant risk assessments must be carried out and documented in the service user’s plan of care to promote the health and welfare of the resident. This is a previous requirement. Individual plans of care must include details of how service users’ personal support needs will be met to guide staff in meeting resident’s care needs. This is a previous requirement. Timescale for action 31/12/07 2. YA6 15(1) 31/12/07 3. YA9 17(1) 31/12/07 4. YA18 15(1) 31/12/07 Shirebrook Views DS0000068253.V355324.R01.S.doc Version 5.2 Page 25 5. YA12 16 6. 7. YA18 YA18 12 16 The home must consult with 31/12/07 service users about a suitable programme of activities. The programme must take account of any educational, and recreational needs of the service users. The home must have a clear and 31/12/07 up to date medical history and health plan for all service users. The home must consult with 31/12/07 service users about issues, which affect their health and welfare and in doing so take account of their wishes and feelings. The home must at all times have suitably, qualified and competent staff appropriate to meet the health and welfare needs of the people they care for. The homes policy and procedures must be updated and reviewed to ensure service users are fully protected from harm. The homes policy on Safeguarding of Adults must be updated and make reference to local procedures. The home must ensure the premises are suitable for the aims and objectives has set out in the Statement of Purpose. The Registered Provider must ensure the home is kept in good sate of repair externally and internally. Comprehensive individual plans of care must be developed for each service user to demonstrate that assessed and changing care needs are being reviewed and addressed. This is a previous requirement. 31/12/07 8. YA18 YA33 18 9. YA23 13 31/12/07 10. YA23 13 31/12/07 11. YA24 23 31/01/08 12. YA24 23 31/01/08 13. 14. YA24 YA26 23 23 The Registered Provider must 31/01/08 ensure that the home is kept in a good state of decoration. The Registered Person must 31/12/07 ensure that suitable curtain are DS0000068253.V355324.R01.S.doc Version 5.2 Page 26 Shirebrook Views 15 16. 17 18. YA30 YA36 YA37 YA37 23 18 8 8 19. YA39 24 20. YA39 24 21. YA42 23 provide to the windows that are street facing. The home must be free of any un pleasant odours All staff must receive regular supervision in line with National Minimum Standards 36.4. The home must appoint a competent manager to run the home A manager must be registered with the Commission to meet requirements and to ensure the home is run in the best interest of the service users. The home must establish and maintain a system for reviewing the quality of care provided to service users. As part of reviewing the quality of care the home must consult with service users, and their representatives. The home must undertake a full test of the water temperatures for Legion Ella. 31/01/08 31/12/07 20/02/08 29/02/08 31/12/07 31/12/07 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA2 YA18 YA25 YA27 Good Practice Recommendations The additional three bedrooms in the short term should be used to facilitate the refurbishment. All service users must be given the opportunity to access the services of an Advocate. The home should provide a screen in the shared bedroom A development plan should be produced for timescales for the provision of en-suite facilities. This is a previous recommendation. Impermeable bathroom floor finishes should be provided. This is a previous recommendation. DS0000068253.V355324.R01.S.doc Version 5.2 Page 27 5. YA27 Shirebrook Views Commission for Social Care Inspection East Midland Regional 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 Views DS0000068253.V355324.R01.S.doc Version 5.2 Page 28 - 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!