Inspection on 05/03/07 for Shirebrook Views

This inspection was carried out on 5th March 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 7 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 21/11/07

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 Andrew Bailey Key Unannounced Inspection 5th March 2007 10:20 Shirebrook Views DS0000068253.V330387.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.V330387.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.V330387.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 11 Category(ies) of Learning disability (11) registration, with number of places Shirebrook Views DS0000068253.V330387.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Shirebrook Views care home is registered to provide accommodation and personal care to service users whose primary care needs fall within the following category: Learning disabilities (LD) The maximum number of persons to be accommodated at Shirebrook Views care home is 11. N/A – New service. Change of ownership. 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, private chiropody and toiletries. These details were confirmed at the time of the visit. Shirebrook Views DS0000068253.V330387.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over approximately six and a half hours. Key inspections take into account a wide range of information and commence before the site visit by examining existing documents and information such as any reported incidents or complaints. The site visit is used to see how a service is performing in practice. The registered person had completed a pre-inspection questionnaire prior to the inspection. No resident surveys were available. The inspection was focused on assessing compliance with specific key National Minimum Standards. On the day of the visit two residents were spoken with at length during the inspection. Case tracking methodology was used to explore the individual care experiences of four out of eleven residents, with particular emphasis on the two residents that were able to give a comprehensive account of life at the home. The acting manager, the responsible individual and two of the staff were also spoken with. There were no relatives available to speak with at this visit. The home experienced a change of ownership towards the end of 2006 and this was the first inspection under the new management arrangements. There is an acting manager in charge of the home and she confirmed that she intends to submit an application to the Commission for the registered manager position. What the service does well: Shirebrook Views is registered for residents with a learning disability and whilst it was not possible to obtain direct and detailed feedback from many of the residents it was clear from observing staff interaction with residents during the visit that there was a caring and supportive approach to meeting residents’ needs. Two of the residents gave detailed feedback about their experiences of the home. The residents spoken with raised no concerns about the care or the facilities and said that they were happy to be living at the home. They praised the staff for their efforts and stated that carers and management are approachable and responsive to any issues that might arise. The residents were satisfied with the catering and laundry arrangements. Both residents were happy to present their bedrooms at the visit and were pleased to have personalised them with their own possessions. One of the residents commented that there are plans to add en-suite facilities to bedrooms and the Shirebrook Views DS0000068253.V330387.R01.S.doc Version 5.2 Page 6 resident was looking forward to this development. The residents described the links they have with specialist community groups outside of the home. Watching TV appeared to be the chief form of entertainment for the residents during time spent within the home. The residents described the assistance that they receive from staff and expressed satisfaction with the level of support that they obtain from staff. The change of ownership had apparently not had significant impact on the residents that were spoken with, although one of the residents commented positively that the central heating comfort levels had improved. 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 of which are summarised below. Care planning is poor overall. Four of eleven care plans (individual service user plans) were examined in detail. None of the care plans examined were of a satisfactory standard, with one at a very poor standard. Whilst two of the more able residents report satisfaction with care at the home, the lack of comprehensive documentation about residents’ health status, needs and progress places them at potential risk. There are no structured plans to guide staff in delivering care and no satisfactory system in place to measure and record progress. Management stated that they were aware that this was an area in need of urgent attention and that they were striving to rectify the care planning recording systems that had been in existence prior to the change of ownership. The home provides a domestic style environment for the eleven residents. However, the level of the facilities falls short of expected standards in some areas, a situation that the new registered provider inherited at change of ownership last year. For example, there is no emergency call system in place at the home. The registered provider has indicated in writing that there are plans to improve the facilities. In the interim, it is very important that risk assessments are undertaken to identify and manage key areas of risk to residents in order to safeguard them as far as possible. This includes risk assessment for residents in respect of the central heating system, which does not have guarded Shirebrook Views DS0000068253.V330387.R01.S.doc Version 5.2 Page 7 radiators, or radiators of a low surface temperature design. Risk assessments must be undertaken as a matter of urgency. The main body of this report contains details of the key shortfalls of the environment potentially affecting the residents. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Shirebrook Views DS0000068253.V330387.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 Views DS0000068253.V330387.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): Standard 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives may be confident that the service will establish that the needs of residents can be met before they move in. EVIDENCE: There have not been any new residents admitted to the care home within the last three years. Therefore, all of the assessments pre-date the current management arrangements following a change of ownership last year. The responsible individual and the acting manager presented the documentation that would be utilised in the event of a new admission to the home and described the system for obtaining social worker assessments (Care Manager assessments, where applicable), in addition to assessment carried out by the staff at the care home. Care plans that should have been developed from assessments are currently of a poor standard. This subject is covered under National Minimum Standard 6 in the next section of this report. Shirebrook Views DS0000068253.V330387.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): Standards 6, 7, 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are no detailed plans of care to demonstrate that residents are treated as individuals and that their health care needs are identified and fully met. EVIDENCE: Four residents were case tracked (out of eleven residents living at the home), which included examination of the care records for these residents. All four sets of care records were of an inferior standard. In one instance the record consisted almost entirely of daily logs, with a brief description of how the resident’s day had been spent and a short comment about the resident’s general state of health. Shirebrook Views DS0000068253.V330387.R01.S.doc Version 5.2 Page 11 In none of the four examples was a systematic process evident whereby care plans had been fully developed from detailed assessments of need, identifying the specific needs to be met, explaining how these needs would be met, and including records of progress at regular intervals. There were initial assessments in some care plans. These were all undated and specific care plans had not always been developed from the assessment information. Three of the four samples had Activities of Daily Living records completed, but with no continuity to provide meaningful care plans from the information derived in the assessments. Where plans of care had been developed these were not signed and dated at the point of issue i.e. no commencement date. The sheets designated as ‘Index of Problems / Needs’ had columns for ‘Date Commenced’ and ‘Date Resolved’. These had not been completed in the majority of instances. There was great inconsistency between the content of care plans, for example in regard to the areas of routine risk assessment. Some of the record files contained templates for risk assessment of nutritional state, skin integrity, continence assessment, moving & handling and risk of falls. In the main these had not been completed and where assessments had been undertaken they presented as once only records, with no reassessments at further points in time. Some records had sheets inserted for the purpose of monthly review of care plans. In none of the case tracked examples had these been completed. Some of the document templates had headers identifying another establishment within the organisation. None of the records contained any evidence that there had been the involvement/agreement of the individual resident or their family/advocate in compiling any information on file. Discussion with two of the residents indicated that care records had not been discussed or agreed with them. It is recognised that with the admission category of this care home not all residents will be able to be fully involved in the process, but there is no apparent system in place to encourage involvement or to record the actual level of involvement of the resident, family or advocate. The Statement of Purpose describes a suitable system under ‘Care Plan Review’, but there is little evidence of the system in action. All of the admissions pre-date the change of ownership. Notwithstanding this, the registered provider has a responsibility to ensure that appropriate records of health status are maintained to safeguard residents. From discussion with the responsible individual and acting manager it was apparent that they were aware that care planning presents as an area for addressing urgently. Shirebrook Views DS0000068253.V330387.R01.S.doc Version 5.2 Page 12 Despite the major shortfalls in care planning, the two residents spoken with felt that they were helped and supported by friendly and competent staff and that their needs were met. They also reported that they were able to make their own choices and decisions as far as possible. However, it must be noted that the two residents present as two of the most independent residents in the home and there could be increased potential risk to more dependent residents given the current standard of care planning and recording. Shirebrook Views DS0000068253.V330387.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have opportunities to develop appropriate and fulfilling lifestyles as part of the larger community. Residents enjoy a balanced and varied diet. EVIDENCE: Two of the residents described the groups that they attend outside of the home. The groups provide transport and both residents stated that they enjoy attending the groups. There had been a trip to Blackpool Sea-life Centre in November and one of the two residents spoken with had been on the trip and said that they had enjoyed it. Shirebrook Views DS0000068253.V330387.R01.S.doc Version 5.2 Page 14 Staff stated that one of the residents who attends a local day centre enjoys woodwork sessions and it was reported that other residents regularly partake in arts and crafts sessions, and gardening. Five of the residents attend a local MENCAP group weekly. The minister visits the home monthly for residents wishing to take part in religious services. Staff reported that families tend to visit more at weekends. Residents spoken with said that their relatives are always made welcome at the home. One of the residents utilises a key to their bedroom and both residents spoken with said that staff maintain their privacy. Residents reported that the food at the home is varied and of a good standard. Residents confirmed that they have a choice at the main mealtime and that preferences are known and responded to by staff. The home is not large in terms of the number of residents or staff and care staff prepare the food for the residents. There is a menu available and the menus examined indicated that the meals are varied and balanced. Staff were observed assisting residents at the midday meal and the mealtime appeared unhurried, with appropriate assistance rendered to residents. The acting manger confirmed that all staff are having planned food hygiene training updates within the next two months. 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.V330387.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents report that their needs are met, but poor documentary procedures do not demonstrate how each resident’s needs are addressed placing residents at potential risk. EVIDENCE: The pre-inspection questionnaire identified that all residents require some assistance with personal health needs. Two of the more independent residents reported that they receive good assistance form staff. As described in the ‘Individual Needs and Choices section of this report there are major shortfalls in the care records. In respect of this section of the report, there is little documentary evidence to describe the nature of the support that staff provide to residents. Choices and preferences are not well recorded and in the main the records fail to identify preferred routines, particularly important where residents cannot always easily communicate their needs and preferences. The involvement of family/advocates is not well Shirebrook Views DS0000068253.V330387.R01.S.doc Version 5.2 Page 16 recorded in this respect. Notwithstanding this discussion with staff indicates 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 to record how residents’ needs are addressed, to safeguard all residents by ensuring that their total needs are identified and responded to. The acting manager confirmed that six-monthly and ad-hoc dental services are in place for residents. Chiropody visits take place every seven weeks and an ophthalmic service is currently being organised for the residents. There are no routine annual health checks for residents either via the community nursing services or the GP’s. This is an area that was discussed at inspection for the acting manager to pursue in order for there to be a pro-active approach to maintaining and improving residents’ health status. There is written guidance for the ordering, safekeeping, administration and disposal of medications. As with all policies and procedures, this is being reviewed by the new provider following change of ownership last year. Medications are stored securely. Medication administration is recorded on Medication Administration Records (MAR sheets). The administration records and storage facilities were examined at this visit and appeared satisfactory. Staff are currently undertaking medication refresher training and this includes a competency element involving the practical assessment of senior designated staff that administer medication. Shirebrook Views DS0000068253.V330387.R01.S.doc Version 5.2 Page 17 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, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A procedure for managing complaints and abuse is in place ensuring residents are protected. EVIDENCE: Care staff were aware that there had been two complaints since the change of ownership, which related to one resident. The complaints were discussed with the responsible individual and the acting manager at this inspection. The complaints had been investigated and responded to in writing within the appropriate timescale. Action had been taken where appropriate in response to the complaints issues. Care staff spoken with were unclear about how complaints would be documented if complaints arose when the manager was not on duty. Staff were aware of the contact arrangements with management out of hours. This is the pathway that they stated would be followed if a complaint arose. Management described the complaints system, which is on display in the reception area. There is 24 hour access for care staff to a member of the management team in the event of a complaint and a whistle-blowing call line is also in operation for staff to use. Shirebrook Views DS0000068253.V330387.R01.S.doc Version 5.2 Page 18 Staff spoken with had received Safeguarding Adults training (Adult Protection/Abuse Training), but the staff were not clear about where the written local guidance is kept at the care home. There has been a recent incident at the home concerning the lifting of a resident, which was referred through to the Safeguarding Adults system. It was agreed for the registered provider to investigate matters. Correct investigation and reporting procedures have been followed to the satisfaction of the Safeguarding Adults strategy team in response to the concern. Residents spoken with felt able to raise any issues of concern with the management and staff and consider them to be very approachable and caring. The system for dealing with residents’ personal monies was discussed with two residents. The residents felt that the system worked well for them and that there were no difficulties accessing their money when they wished to. The acting manager described the system at inspection and the systems appeared to be satisfactory. Shirebrook Views DS0000068253.V330387.R01.S.doc Version 5.2 Page 19 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 23, 24, 25, 26, 27, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a homely environment, but there is potential hazard to their welfare, which needs to be risk assessed and managed accordingly. EVIDENCE: Shirebrook Views provides a domestic style environment for the eleven residents, all of which have lived at the home for three or more years. The two residents spoken with were satisfied with the home’s communal facilities and with their private accommodation. Both residents were happy to present their bedrooms for viewing at inspection and were pleased to have been able to personalise their rooms with their own possessions. One of the residents had been informed of plans to upgrade the bedrooms with the Shirebrook Views DS0000068253.V330387.R01.S.doc Version 5.2 Page 20 installation of en-suite facilities and the resident was looking forward to this development. The current owners took over the home towards the end of 2006 and there have not been any major changes to the environment since the takeover. The Statement of Purpose explains that the first floor accommodation is not suitable for residents with mobility difficulties. This is because there is no lift access. The entrance area also has a few steps to descend to the main ground floor level of the home and there is a stair lift for use where needed. The registered provider has indicated in writing that there are plans to improve the facilities. Improvements include: Relocating the laundry, fitting a system of locks to bedroom doors (for residents to use if they wish to), and the fitting of an emergency call system. Some of the environmental shortfalls present cause for concern for the potential safety and welfare of residents. In the interim, whilst plans are being finalised for works it is very important that risk assessments be undertaken to identify and manage key areas of risk to residents in order to safeguard them as far as possible. This must include risk assessment to address the lack of an emergency call system and identify what measures are in place for residents and staff in the event of an emergency. Risk assessments must be undertaken as a matter of urgency. None of the bedrooms currently offer en-suite facilities and the bathrooms and toilets all have carpet as a floor covering, which is not easily cleanable. The laundry is not well sited on the second floor and a thoroughfare for access to some of the bedrooms. The laundry also has a carpeted floor covering and, as such, is permeable. Infection control update training is planned to take place within the next two months. Shirebrook Views DS0000068253.V330387.R01.S.doc Version 5.2 Page 21 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has sufficient staff, appropriately recruited and trained to support and assist the residents. EVIDENCE: Two residents were spoken with as part of the case tracking methodology. Both residents considered the staff to be approachable, helpful and competent. They felt that staff were respectful of their privacy and dignity and felt able to raise any queries or concerns with them. The residents felt there to be sufficient staff on duty at the home. Three of the seven care staff employed had undertaken National Vocational Qualification (NVQ) training. A further three staff are due to commence training in April 2007. Shirebrook Views DS0000068253.V330387.R01.S.doc Version 5.2 Page 22 The recruitment file of a staff member recently employed was examined at this inspection. There was evidence of a robust checking system in place to protect the residents. There is an induction and on-going training document for staff to work through. The acting manager explained that it is planned for all staff including existing staff) to utilise this training document. Shirebrook Views DS0000068253.V330387.R01.S.doc Version 5.2 Page 23 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, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are some potential health and safety risks to evaluate and manage to ensure that residents are suitably protected EVIDENCE: There is an acting manager in charge at the home. This is an acting position because the manager has not yet applied to be registered with the Commission as the registered manager. The manager intends to submit her application in the near future. The acting manager is nearing completion of the Registered Managers Award. Shirebrook Views DS0000068253.V330387.R01.S.doc Version 5.2 Page 24 There has not been a survey of residents/relatives satisfaction since the change of ownership, but the views of the residents are sought on a one-toone basis on a regular basis. There are also informal meetings held with relatives e.g. coffee afternoons. Views are also obtained during the mandatory visits by the registered persons (responsible individual) in respect of Regulation 26 visits (legally required visits to the home by the registered persons to interview residents and check various quality and performance matters on a monthly basis). The acting manager also provides monthly reports to the registered provider on an audit of medicines, audit of accidents/incidents and complaints. The responsible individual present at the inspection explained that the company is developing a quality assurance tool for use in the group of homes. There is a schedule for staff mandatory training updates and the acting manager envisages that all staff will have received refresher training within the next two months in aspects of safe working practice. There was no evidence of a risk assessment by a competent person to identify if any specific Legionella prevention measures are appropriate at the care home. There are some environmental/health & safety shortfalls present that give cause for concern for the potential safety and welfare of residents. The registered provider has indicated in writing that there are plans to improve the facilities. Improvements include: Fitting of low surface temperature radiators, and fitting of thermostatic valves to bathrooms and washbasins. In the interim, whilst plans are being finalised for development works at the home it is essential that risk assessments be undertaken to identify and manage key areas of risk to residents in order to safeguard them as far as possible. This must include risk assessment for residents in respect of the central heating and hot water system, which does not have guarded radiators, radiators of a low surface temperature design or thermostatic mixer valves for prevention of scalding from hot taps. Risk assessments must be undertaken as a matter of urgency. 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. Shirebrook Views DS0000068253.V330387.R01.S.doc Version 5.2 Page 25 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 X 29 2 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 1 3 X 1 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 X 2 X 3 X X 2 X Shirebrook Views DS0000068253.V330387.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A 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 Individual plans of care must be drawn up with the involvement of the resident (family or advocate where appropriate) so that they fully reflect the assessed needs of the resident Relevant risk assessments must be carried out and documented in the resident’s plan of care to promote the health and welfare of the resident Individual plans of care must include details of how residents’ personal support needs will be met to guide staff in meeting resident’s care needs A risk assessment must be undertaken to identify and manage any risks to residents in the absence of an emergency call system A manager must be registered with the Commission to meet requirements and endorse that DS0000068253.V330387.R01.S.doc Timescale for action 30/04/07 2 YA6 15(1) 30/04/07 3 YA9 17(1) 30/04/07 4 YA18 15(1) 30/04/07 5 YA29 23(2)(a) 30/04/07 6 YA37 8(1) 30/04/07 Shirebrook Views Version 5.2 Page 27 7 YA42 13(4) residents benefit from a home run by a competent and qualified person Radiators and hot water outlets within the home must be assessed for the risk they present to residents and action taken to minimise any identified risk 30/04/07 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 5 6 Refer to Standard YA6 YA19 YA27 YA27 YA30 YA42 Good Practice Recommendations Individual plans of care should be signed and dated by the person developing the plans Service users should be offered minimum annual health checks A development plan should be produced for timescales for the provision of en-suite facilities Impermeable bathroom floor finishes should be provided The laundry should be re-sited so that it does not present a thoroughfare for residents and should have an impermeable floor finish An assessment should be made by a competent person of the risk and management of any Legionella risk presented by the hot and cold water system Shirebrook Views DS0000068253.V330387.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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