Inspection on 19/01/07 for The Shires

This inspection was carried out on 19th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Shires 28/02/06

The Shires 16/09/05

The Shires 15/12/04

The Shires 13/07/04

The Shires 25/02/04

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

CARE HOME ADULTS 18-65 Shires The 116 Aylestone Hill Hereford Herefordshire HR1 1JJ Lead Inspector Debra Lewis Unannounced Inspection 19th January 2007 10:00 Shires The DS0000027691.V312547.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 Shires The DS0000027691.V312547.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. Shires The DS0000027691.V312547.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shires The Address 116 Aylestone Hill Hereford Herefordshire HR1 1JJ 01432 271785 01432 276806 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) Herefordshire Mind Association Mr Allan John Riley Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (13) Shires The DS0000027691.V312547.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2006 Brief Description of the Service: The Shires is a 3-storey Victorian house set in extensive grounds that are well maintained and easily accessible, with open views overlooking the Lugg Meadows. It is on the outskirts of Hereford, which offers shopping and recreational facilities. There is a small newsagents shop within very close walking distance. There are nine single bedrooms and two shared double bedrooms, none of which have en-suite facilities. The home is fitted with a passenger lift to all floors with the exception of the second floor. The two bedrooms on the second floor are used specifically for service users with a greater degree of independent living skills. The home provides accommodation, care and nursing for up to 13 adults (some over 65) with enduring mental health needs. The Primary Care Trust owns the property. The provision of security of tenure through a Service Level Agreement with the Primary Care Trust is unresolved. The registered provider of the service is Herefordshire MIND and their General Manager, Mr Andrew Strong, is the responsible individual. The registered manager of the home is Mr Allan Riley. Mr Riley also manages a counselling & psychotherapy service and a supported living service. The home has appointed a second manager to be in charge of day-to-day running of the home, Ms Andrea Frater. Her application for registration is currently being processed by CSCI (Commission for Social Care Inspection). Information about the home is available in a detailed service users’ guide. Fees for the home range from £418.62 to £ 495.80 per week (for an incounty placement, with the health component funded by Herefordshire PCT) or £932.75 (for an out of county placement). Shires The DS0000027691.V312547.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first inspection of 2006-7. It was a Key Inspection. This means that the inspector checked all of the standards which have most impact on service users, taking into account any information received about the home and including a visit to the home. The inspector was in the home from 10 a.m. until early evening. The inspector met and talked with several service users; with staff on duty; and with the registered manager, Allan Riley. All were welcoming and gave useful information. Several service users spent a length of time with the inspector and were very helpful. The inspector sent questionnaires about the home to service users and to their relatives. 10 service users and 14 relatives returned the questionnaire. Their views are taken into account in this report. The inspector was assisted by an Expert by Experience (in this report known as “the Expert”). This is someone with personal experience of using mental health services, who has been trained to accompany CSCI (Commission for Social Care Inspection) inspectors during inspections. Their aim is to observe what happens in the home and talk to service users, to acquire a service users’ point of view of the home. The Expert talked with many service users and provided a report of her findings. Parts of her report have been included in this report. What the service does well: Before people move into The Shires, staff make sure they know what care the person will need. The care people need is written down and kept up to date, and service users can be involved with this if they want. Service users say they can make their own decisions and can live independent lives. Staff help them to do so as safely as possible. Service users can do training, education or work if they want. They do ordinary activities like going to the gym or to see plays or bands. Relatives are welcome in the home. Daily life is not restrictive. The home provides a good variety of food and caters well for special diets. Service users like the food. Staff help service users to keep healthy and to feel secure. They look after medication safely. Staff are open to listening to any concerns. Service users and relatives feel comfortable with raising concerns and say the home acts on them. During the past year CSCI has not received any complaints about The Shires. The home is mostly clean, homely and well maintained. Shires The DS0000027691.V312547.R01.S.doc Version 5.2 Page 6 There are enough staff in the home to give the care people need. Staff are suitably qualified, and service users like them. The home checks staff before they start work in the home, to reduce the risk of employing unsuitable people. Service users are involved with interviewing staff. Service users and staff like both managers and say they do a good job. The home finds out what service users think of the home and makes changes as a result. They also check the quality of their service regularly. The home is generally safe. 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. Shires The DS0000027691.V312547.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 Shires The DS0000027691.V312547.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): 2 Quality in this outcome area is good. Service users’ needs were being assessed before they move into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service user plans contained detailed assessments of their needs, which were included in notes of their history and background. These were not dated. Assessments had been used as the basis for drawing up service user plans. The service user plan for someone recently admitted to the home included a full CPA (care programme approach) assessment, so staff were fully aware of that person’s care needs before they came to the home. Shires The DS0000027691.V312547.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): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user plans were up to date and some service users were involved with them. Service users were able to make choices about their lives, and to take ordinary risks, while the home assessed how to reduce risks. EVIDENCE: The inspector looked at a sample of service user plans. They were detailed and up to date, all having been reviewed twice in 2006 (or as needed) as is good practice, with service user involvement. It included individual positive approaches to aggression or risk of self-harm. Service users each had a named nurse and a primary carer, although any staff on duty gave general support. 2 service users told the inspector they felt they did not have much to do with their service user plans, but another person said they had full involvement and could change anything about the plans. This could reflect varying practice among staff or varying levels of interest in such matters among service users. The inspector advised that service user plans could be improved by ensuring that positive aspects of service users’ lives (e.g. social needs, aspirations, Shires The DS0000027691.V312547.R01.S.doc Version 5.2 Page 10 education, spiritual interests) were included in the plans. The registered manager said this was already being planned. Service users almost entirely felt they were able to make their own decisions and choices. There was a very small indication that some staff may be more restrictive than others, but overall service users were very happy with their access to choice. One service user said they had been in other care services and the Shires is “no way an institution, there’s so much choice here.” Another person said “everyone here is a free agent”. One person was getting the help of an independent advocate with making a complaint (about a service unconnected with the home). Most service users managed their own finances. Service users were involved with staff appointments and their input had been much valued by staff. The Expert commented that “Residents appreciated the flexibility of the staff in supporting them to choose what to do,” and noted that sometimes service users may need options explained in order to make a choice. Service users were able to lead independent lives and to undertake ordinary activities with some risks associated. Risks were evaluated either in risk assessments (all of which had been reviewed in 2006) or in service user plans. The home had a procedure to follow if a resident went missing. Shires The DS0000027691.V312547.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): 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. Service users were encouraged to take up education or work if appropriate, and to take part in ordinary activities within the general community. Relatives were welcome in the home and daily routines were unrestrictive. A good range of food was supplied, and the home catered well for individual service users’ dietary needs. EVIDENCE: Service users’ involvement with work, training or education varied widely according to individual needs. One person was frequently stressed by symptoms of their mental ill health and therefore had limited activities outside the home. Another had completed an Open University course while at the home and another was having music lessons. Service users took part in ordinary community activities, including at weekends and in evenings. This was also dependent on choice and interest; Shires The DS0000027691.V312547.R01.S.doc Version 5.2 Page 12 service users mentioned visits to the theatre in Malvern, music groups, gym and keep fit classes, and staff mentioned accompanying service users to see a show or a band. The Expert noted that “No one complained of being unable to go out due to lack of staff. A lot of service users feel able to go on their own and are encouraged to use community facilities.” 14 relatives responded to the CSCI survey and all indicated they felt welcome in the home at any time and could visit their relative in private, albeit in their own room. 2 said they felt the home preferred to know in advance. This is understandable, as service users could be out of the home or due to attend a medical appointment, as long as relatives still feel they can turn up unannounced. In addition, the home had begun to hold relatives’ meetings every 3 months, giving a valuable opportunity for relatives to keep involved and in touch with the home. Daily routines were unrestrictive, service users said they were called by their preferred name, they held keys for their rooms and for the home, they opened their own post, and staff knocked and waited before entering their bedrooms. The inspector observed staff interacting freely with service users in a friendly and sociable manner. Service users said they had some responsibility for housekeeping tasks and were able to choose the task they preferred. The inspector sampled a meal, saw the menu and discussed the food with service users and staff. Service users liked the food and said they could always choose an alternative if they did not like the offered meal. The inspector saw this in action. Service users were able to get involved in food preparation to some extent although this was somewhat limited by having only one large, catering sized kitchen. One service user ate a vegan diet and said this was excellently provided by the home; they were never made to feel like a nuisance or as if they were being fussy. The inspector saw detailed dietary plans for agreed food intake for people with specific dietary needs. One service user chose to eat in their own room and this was respected. The Expert noticed that the availability of choice meant that some service users sometimes chose to buy takeaways and caffeinated drinks, which may not be healthy choices. Staff could consider ways of service users getting information about healthy diets and effects of diet on mental and physical health. Shires The DS0000027691.V312547.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): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needed little help with personal care; help was given sensitively. Staff supported service users well with their health care needs and kept accurate detailed records of any interventions. Medication was safely managed. EVIDENCE: Service users needed very little personal care. Staff described how they assisted with showers or baths for one person, but their help was limited to ensuring safety and was given discreetly. Some service users needed a little encouraging or prompting with personal hygiene and this was clearly recorded (in respectful language) in their service user plans. Service user plans included detailed plans for supporting service users with specific health conditions or needs, e.g. epilepsy, diabetes, and monitoring of health related to taking a specific medication. Separate records were kept for each person’s medical contacts and detailed medical notes were also kept. Discussing mental health needs, one service user said before they came to The Shires they had become unwell and gone into hospital every few months. Shires The DS0000027691.V312547.R01.S.doc Version 5.2 Page 14 However, over the 5 years they had been in the home, they had never needed to go into hospital. Previous requirements related to medication management had been met. The inspector saw medication storage, administration and records including records of medication received in the home and administered to service users, records of current medication and of service users’ consent to take medication. All were satisfactory. Records of medications removed from the home were unavailable, as unwanted medications were now being disposed of by a waste disposal company not via a pharmacist. The inspector advised these records must still be kept in the home, and the registered manager reinstated the process immediately. Keys were kept securely. There was separate storage for controlled drugs if needed and for medications needing refrigeration. Medication was only administered by trained nurses, who received induction training in the home’s procedures and were then shadowed by another experienced nurse until they were judged to be competent to administer medication. The home had a medication policy which included guidance on managing errors. An error had occurred and was reported by the staff member responsible. The inspector saw evidence of the open and fair way in which the incident was managed, with an emphasis on understanding and clarifying where the system broke down. This is a commendable approach as it encourages openness rather than secrecy and enables staff and the service as a whole to learn from any errors. Some service users had “as required” medications and in each case there was a fully detailed protocol describing the circumstances in which it would be used. The registered manager explained that, because of the complex nature of service users’ needs in this home, none were looking after their own medication and this was explicitly stated in the policy. However a self – medication training period took place if a service user was preparing to leave the home to live more independently. Shires The DS0000027691.V312547.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): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had policies on complaints and adult protection. Service users and relatives knew how to make a complaint and almost all felt confident to do so. EVIDENCE: The home had a suitable complaints procedure and this was displayed on the notice board (although the contact details for CSCI were out of date as the relevant office changed from July 2006). 10 service users responded to the CSCI survey and all said they knew who to talk to if they had a concern, and they were aware of the complaints procedure. In conversation with the service users, 2 said they would be very comfortable with making a complaint. One had done so in the past and had positive results, with changes made to how staff worked. A third person said they would be happy to raise a concern except with one particular staff member who he got on less well with; the registered manager was aware of this. Another said they would not make a complaint, as based on their experiences in institutions over the years, this inevitably caused trouble for the complainant. The inspector judged this to be more reflective of the person’s previous bad experiences than of practice in the home, as it seemed to be at odds with the experience of other service users. A relative had made a complaint in the past which they said had been handled well by the home. CSCI had not received any complaints about the home. The home had a suitable policy on Protection of Vulnerable Adults. Staff training records indicated that 10 out of the 18 staff had done training in this during 2006, but the other 8 either had not had such training or it was out of date. Shires The DS0000027691.V312547.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 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 clean, homely and well maintained. There were no ensuite facilities and no private meeting room for visitors. EVIDENCE: The inspector toured the home and saw some bedrooms. The home was clean, homely and well maintained. There was evidence of attention to safety, e.g. harmful chemicals were stored safely, windows above ground floor level had restrictors. The Expert commented that “The house appeared very well looked after and the large windows in the lounge seemed very clean. I felt it had a very therapeutic atmosphere.” No bedrooms had ensuite facilities and 2 bedrooms were shared. These conditions pre-existed the NMS (national minimum standards) so are acceptable, but not ideal. Shires The DS0000027691.V312547.R01.S.doc Version 5.2 Page 17 Individual bedrooms were furnished according to the tastes of the occupant. One bedroom was dirty; the staff member explained this was due to a combination of the occupant’s smoking, making drinks and not being too keen on cleaning. Staff supported this person with cleaning on a regular basis, but perhaps the frequency could be increased to maintain reasonable levels of cleanliness. Bedrooms were lockable and service users held keys for their rooms. The Expert looked at arrangements for managing privacy and space for the female service users in the home. She noted that “The gender imbalance concerned the female service users I talked to. They all liked living in the Shires but there was no gender separation of bedrooms and no designated female showers and toilets. The service users have changed over the years and females are in the minority and the men are younger. One service user complained about the men swearing at her and one …… felt that some of the male service users did not respect her space.” The home’ shared areas were a lounge, a dining room and a small smoking room. There was no private space for visitors, other than the service users’ own bedrooms. The Expert commented that “There is a lack of public space with only a lounge and a dining room, which is also used for staff meals and handovers although it contains an area for service users to prepare hot drinks. All food is provided from the kitchen which is not available to service users on a regular basis who may like to prepare their own meals,” and “It was difficult to find private space to talk with the inspector; this also affected the options available to me when talking to residents as I had hoped to offer them a private space.” The home was clean and free from unpleasant odours during the inspection, other than the room mentioned above. They had policies covering infection control and disposal of clinical waste. The laundry was suitably equipped and was situated well away from any food storage or preparation areas. Shires The DS0000027691.V312547.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were enough staff in the home, and they had good working relationships with service users. Appropriate checks were carried out on staff before they began work in the home, to reduce the risk of employing unsuitable staff. Staff held qualifications suited to their work, and undertook further training, but some training needed to be updated. EVIDENCE: Staff in the home had good competencies and qualities to meet service users’ needs. In addition to the managers, there were 5 qualified nurses. Of the support workers, 4 out of 9 held NVQs (national vocational qualifications) at level 2 or 3 and some had some counselling training. The inspector observed all staff on duty interacting with service users in a professional, respectful, friendly and approachable way. Of the ten service users who replied to the CSCI survey, all said staff always or usually treated them well. Service users at the inspection were positive about staff, with comments such as “The help I get is tremendous”, “staff are very nice, my key worker helps by talking to me”, “Staff always say come and find us if you need us, even if we’re really busy.” Shires The DS0000027691.V312547.R01.S.doc Version 5.2 Page 19 The home had sufficient staff on duty, with a qualified nurse in charge of each shift, day and night. There are also 2 or 3 support workers and a housekeeper on duty during the day, and a support worker on duty with the nurse at night. The rota did not always show the hours worked in the home by the registered manager, Allan Riley. There was a stable staff team and staff meetings were held approximately every 6 weeks. The home carried out appropriate pre-employment checks on staff, including ensuring full, satisfactory CRB checks were received before staff worked in the home. This included volunteers and gardeners / maintenance workers. Employment records were kept in the MIND office, not in the home, but the inspector was told she would be welcome to view them at any time. Service users were involved with staff recruitment, with a service user representative on the interview panel. The home kept full and up to date records of staff training. These records showed that basic training took place in a range of topics, including Protection of Vulnerable Adults, Moving and Handling, Health and Safety, Food Hygiene, Managing Aggression, First Aid and Fire Safety. However in a significant number of cases, training or refresher training was overdue. The registered manager explained that this was at least partly due to a significant intake of newly appointed staff during the past year. It may also benefit staff and service users if staff attended other courses on specific topics e.g. self-harm, counselling skills. Shires The DS0000027691.V312547.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager is suitable trained and experienced to manage the home; a second manager has been appointed to share the day-to-day responsibilities. The home audits its service, including seeking the views of service users, and the results feed into an annual plan for the home. Health and safety is mostly well managed, with some aspects needing to be updated. EVIDENCE: The management arrangements for the home were unusual. The existing registered manager, Allan Riley, also manages other Mind projects so has limited time in the home. A new joint manager has been appointed, Andrea Frater. Responsibilities are shared. Ms Frater is in charge of the day-to-day Shires The DS0000027691.V312547.R01.S.doc Version 5.2 Page 21 management of the home; Mr Riley is the Senior Manager and covers overall management of the home, administration such as policy reviews, and auditing. Ms Frater has applied to be registered with CSCI, and her application is being processed. She is a qualified mental health nurse. Mr Riley is well qualified and experienced to manage the home. He is a Registered Mental Nurse and has managed the home for the last 11 years. He aslo holds teaching and assessing certificates, a Bachelor of Science degree with honours in Health Studies and a Post Graduate Diploma in Management. Staff and service users spoke well of both managers and felt the management arangements were working satisfactorily. The home auditted its service in various ways, including service user surveys, relatives’ meetings (relatives’ surveys were being planned), audits of care plans , medcation and othjer areas of work. A full auduit had taken place against the NMS (national minimum standard) approximately 18 months ago, and audits were done of MIND’s quality standards including health and safety and service user involvment. Mr Riley expalined that all of these, together with the CSCI inspection reports, fed into an annual operation plan for the home. Health and safety in the home was mostly well managed, but some aspects needed attention. The inspector saw records showing that items such as electrical installations and equipment, gas appliances, fire safety equipment and lifts were being serviced and maintained appropriately. There were general risk assessments for the home covering most safe working practice topics, though not all of those in NMS (national minimum standard) 42; they had been updated in 2006. There was a fire risk assessment which had been done in 2006. Fire safety training for staff had taken place twice during 2006, but the records did not show which staff had attended. Training was planned to take place at least 4 times during 2007. Fire drills had been held on 5 occasions during 2006, but not all staff had been included in one of these drills. Detailed records were kept of who was involved, and analysing the response to the drills. Most fire safety checks were being done as required, but the inspector did not see records of monthly checks on emergency lighting and of self-closing doors. Water temperature checks had been done but the recording had lapsed since last summer. Shires The DS0000027691.V312547.R01.S.doc Version 5.2 Page 22 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 3 25 X 26 3 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 X 3 X X 2 X Shires The DS0000027691.V312547.R01.S.doc Version 5.2 Page 23 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 2 3 Standard YA23 YA20 YA30 Regulation 13 13 13, 16 Requirement All staff must have up to date training in Adult Protection. The home must keep a record of all medication which they dispose of. Staff must ensure that all parts of the home are kept to reasonable standards of cleanliness, if necessary by increasing the frequency of support for individual service users. Staff training in core topics must be kept up to date. The water temperature of baths and showers must be checked and recorded each month. If the temperature is outside of the required limits it must be reported and addressed as a matter of urgency. (Previous timescale of 03/03/06 not met) The home must keep written risk assessments covering safe working practice topics as listed in NMS (national minimum standard) 42. All fire checks must be carried out at the required intervals, DS0000027691.V312547.R01.S.doc Timescale for action 31/03/07 28/02/07 28/02/07 4 5 YA35 YA42 18 13 30/06/07 28/02/07 6 YA42 13 28/02/07 7 YA42 23 28/02/07 Shires The Version 5.2 Page 24 8 9 YA42 YA42 23 23 including monthly checks on emergency lighting and automatic door closures. All staff must take part in a fire drill at least once a year. All staff must receive fire safety training at least 4 times a year. 28/02/07 28/02/07 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 Refer to Standard YA6 YA6 YA20 YA30 YA33 Good Practice Recommendations Staff should work with key clients to ensure that everyone is aware of their service user plans and has as much involvement with them as they want. Service user plans should include details of positive aspects of service users’ lives e.g. social needs, education, aspirations etc. The registered manager should ensure there is a clear policy on assessing each individual’s ability to selfmedicate. Staff should investigate whether it is possible to clean service users’ mattresses if necessary. The staff rota should include the times when the registered manager is in the home. (Carried forward from September 2005 and February 2006) The registered manager should consider accessing further training for staff as appropriate to the home, e.g. in specific mental health topics or in counselling skills. 6 YA35 Shires The DS0000027691.V312547.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Shires The DS0000027691.V312547.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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