Inspection on 19/05/09 for The Shires

This inspection was carried out on 19th May 2009.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Shires 29/11/08

The Shires 23/06/08

The Shires 04/07/06

Extracts from inspection reports are licensed from CQC, this page was updated on 10/07/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE The Shires 12 - 13 Gorringe Road Eastbourne East Sussex BN22 8XL Lead Inspector Lucy Green Unannounced Inspection 19th May 2009 08:35 DS0000067518.V375519.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Shires Address 12 - 13 Gorringe Road Eastbourne East Sussex BN22 8XL 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) 01323 721032 01323 646771 christineb66669@aol.com Eaglecrest Care Management Ltd Manager post vacant Care Home 27 Category(ies) of Dementia (0) registration, with number of places The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - PC to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Dementia - DE The maximum number of service users who can be accommodated is: 27 18th February 2009 Date of last inspection Brief Description of the Service: The Shires is a care home registered to provide accommodation and care for twenty-seven older people with a dementia type illness. Intermediate care is not provided. The home is situated in a residential area of Eastbourne, approximately two miles from the town centre. The Shires provides twenty-four single rooms, fourteen of which have en-suite toilet and hand basin facilities. There are three double bedrooms. There are two assisted baths and two assisted shower facilities. The home provides a range of communal space, including a conservatory and a large, accessible rear garden. There is a stair lift to access the first floor accommodation. More information about the services provided by the home, including the current range of fees can be found in the homes Statement of Purpose and Service User Guide. Copies of both these documents can be obtained directly from the Provider. The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulations 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at The Shires are referred to as ‘residents’. This report reflects a key inspection based on the collation of information received since the last inspection, a review of the home’s Annual Quality Assurance Assessment and an unannounced site visit which was conducted by two Inspectors on Tuesday 19th May 2009 and lasted for a total of five hours between 8:35am and 1:35pm. The site visit included a partial tour of the home and an examination of some care, medication and staffing records. The Inspectors observed the interaction between staff and residents as they undertook their morning routines and ate their lunchtime meal. At the time of this inspection, there were twenty people living at The Shires. Throughout the inspection process, the Inspectors saw most of the residents and spoke individually with eleven of them. Three visitors were interviewed during the visit and time was also spent with staff and the Manager and the Deputy Manager and a carer were interviewed in private. What the service does well: Residents are supported by a professional and kind team of staff who were observed treating residents with dignity and respect at all times during the inspection. Residents spoke highly of staff and discussion with two visitors confirmed that they are also impressed with the attitude of staff whom the described as being respectful, friendly and caring. The physical environment of the home offers a pleasant place for residents to live in. Bedrooms are personalised and residents are encouraged to make rooms their own. The Registered Provider now has a rolling programme of maintenance and residents have a choice of comfortable communal and private spaces to spend their time. The rear garden provides outside space for residents to wander and spend time in the warmer weather. The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 6 The home recognises the importance of good relationships with other stakeholders and as such has good links with local healthcare professionals and relatives and visitors are welcomed into the home at any time. Meals are entirely homemade and menus are varied and offer choice and variety. What has improved since the last inspection? The last key inspection was conducted in November 2008 and the identification of poor outcomes for the people living at The Shires led to the Commission taking enforcement action against the home. A follow up visit was made to the service in February 2009, where it was noticed that the home had begun to make some improvements and the appointment of a new qualified and experienced Manager led Inspectors to the decision that the service should be given additional time to meet the outstanding requirements. It is pleasing to report that this inspection has been able to evidence the hard work invested by the newly appointed Manager and the longstanding Deputy Manager. It is evident that the respective skills, knowledge and experience of these two individuals compliment each other well and together they have been able to move the service out of the Commissions enforcement pathways. The current Manager is the seventh to have been appointed since 2005 and his commitment to the service in the last three months, alongside his completion of the registration process finally provides some stability and leadership to the management of this home. At the time of the last inspection, there were a high number of outstanding requirements and it is therefore positive that over the last few months the home have worked hard to comply with these. The home have implemented a complete overhaul of the documentation systems and this has had led to the provision of high quality care records that will enable the people living at the home to have confidence that their individual needs and expectations are identified, understood and ultimately met. The Manager has also introduced a more robust approach to the recruitment and development of staff. Staffing levels have been increased and people can now be confident that the staff who support them have been appropriately checked and given opportunities to undertake mandatory training. The overall ethos of the home has changed and staff were observed to be much more confident in their approach to offering choice and flexibility to residents. We noticed that staff now support residents at their own pace and as such respect that people have individual routines. The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 7 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective service users would benefit from the provision of more up to date and accessible information about the services provided at the home to enable them to decide if the Shires can meet their needs and expectations. EVIDENCE: At the random inspection conducted on 18/02/09, it was identified that the Statement of Purpose had not been updated and as such was not fully reflective of the services provided. The Service User Guide also needed reviewing and updating. During a conversation with the Manager at the time of this inspection it was highlighted that he has not yet had the opportunity to review the Statement of Purpose and Service User Guide. The Manager stated that he was aware that both needed updating and that they were on his action plan of things to do, but that he had not made this task an immediate priority. The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 10 The Inspectors advised that the home has seven vacancies and that these documents would be required if they were to assess a prospective new resident. This was acknowledged by the Manager and it was agreed that a requirement would be made for both the Statement of Purpose & Service User Guide to be updated. The Manager confirmed the information supplied in the AQQA and latest Regulation 26 visit, that there have not been any new admissions since the time of the last inspection. The Registered Provider voluntarily agreed to initially suspend admissions for a period of two months following the random inspection in February 2009 to enable the Manager to focus on meeting outstanding requirements. At the last inspection on 18/02/09, the previous Inspector viewed the preadmission assessment for a person who had been recently admitted. The information gathered at this time identified that the previous outstanding requirement had been met and the information included sufficient detail to demonstrate The Shires was able to meet this individuals needs. It was evidenced at this inspection that the information obtained during the assessment of this person has now been transferred into a comprehensive plan of care. The individual was observed by Inspectors and confirmed by the Manager and Deputy Manager to have settled in well at the home. The Manager confirmed that prospective residents and/or their representatives are encouraged to visit the home prior to admission to assess the suitability of the placement. Feedback from two of the visitors spoken with confirmed that that they had had the opportunity to visit the home prior to their relative moving in. There is no provision for intermediate care at The Shires and therefore Standard 6 is not applicable. The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst basic care needs are now being met, outcomes for residents will be improve once the new more person centred care plans are being strategically used to formulate goals and holistically deliver consistent care. EVIDENCE: The area of care planning was highlighted as one of major concern at previous inspections. As such the Manager and Deputy Manager have spent much of the last three months, reviewing each residents care needs and updating care plans onto a new system. The Manager has introduced a computerised system of care planning and once fully up and running, it was reported that each staff member would have their own their own login and password to enable the home to easily track when and The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 12 by whom entries have been made. This system also enables staff to be electronically reminded when reviews or appointments are scheduled. For the purpose of accessibility, the care plans have been printed and individual files compiled. Each month key parts of the care plan are updated and re-printed as part of the reviewing process. The Manager advised that nineteen of the twenty people accommodated at The Shires now have an updated and revised plan of care. Once the final care plan has been completed, the Manager has said he will ensure that any other relevant information from the existing care plans will be transferred to the new file and hence each person will then have a fully current and comprehensive care plan. Once fully integrated and embedded in the service, the new system has the potential to work very well. A sample of four care plans were viewed and it was evident that each of these residents now have a plan of care that provides detailed information about their health and welfare needs, with evidence of multi-disciplinary input as necessary. It is positive that the information gathered by Inspectors about care needs from their observation and interaction with residents and staff was reflective of the information contained in the care plans. Care plans contain some risk assessments. The Inspectors did however identify that risk assessments for two people needed to be further developed. The Manager confirmed that he was aware of this and produced an action plan which detailed both as outstanding areas of work. In line with a requirement from the last inspection, each resident now has now been assessed in respect of dependency, risk of falls and tissue viability. With the exception of one person, each resident has been re-assessed and an entirely new plan of care compiled since February 2009. Therefore the care plans viewed were found to be up to date. The majority of residents have now been allocated keyworkers, who the Manager is in the process of training to conduct monthly care plan reviews. Where residents have other people who represent them, there was documentary evidence that they had also been consulted with. It was evident in the care plan for one resident that the home recognises that people can become less dependent as well as requiring increased levels of support. Staff practices observed throughout the inspection demonstrated that they have a good understanding of the residents and their needs. Discussion with three staff produced evidence that they have a good knowledge about the people they support. Once the new system is fully operational, the home will again need to review staffing levels to ensure that there are sufficient staff the care and support identified. Feedback from two visitors highlighted that their view of staff was that they are always very busy and as such it is the small things that get forgotten. The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 13 Residents are supported with their health care needs and care plans contain a record of any visits or contact with professionals external to the home. Any input or advice is then reflected in the relevant care plan and subsequent monthly review. There was evidence of current involvement from General Practitioner, Dentists and Chiropodists. Records demonstrated that residents are weighed on a monthly basis and appropriate action is taken accordingly. Medication systems were inspected by way of a review of the Medication Administration Records (MAR sheets) and examination of the storage of medication. The medication policy was not inspected on this occasion. The Manager confirmed that only senior staff who have been appropriately trained and supervised handle medication. The Pharmacist Inspector who visited at the random inspection recommended that the service introduce individual care plans for the use of medication that is prescribed for only when needed. This was stated to ensure that the common approach to this type of medication is person centred. The Deputy Manager confirmed that the home does have guidelines in respect of this issue, but that further work on the care plans will include this criteria. This issue is reflected as a requirement of this inspection. The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from some opportunities to participate in activities. Outcomes would be further improved if activities were linked to person centred plans of care and were reflective of their individual likes and interests. Food is varied and wholesome, but greater thought is needed for those who may not eat and drink sufficiently at designated mealtimes. EVIDENCE: The daily running of the home was observed to provide residents with the flexibility and choice about how and where to spend their time. On the Inspectors arrival at the home it was evident that individual routines were being respected by staff and residents are able to get up as early or late as they wish. A menu of the main lunchtime meal is displayed and a Senior carer advised that residents are offered their choices of main meal they day before. It was The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 15 confirmed by staff and the records of food that there is always a vegetarian option. The food served at the time of the inspection was either cottage pie and cheese topping, cabbage or ham and/or egg salad. The lunchtime meal looked appetising and well presented and residents received appropriate support in a sensitive and dignified way. The Inspectors observed that one resident refused their lunch and two others ate very little. This was discussed with staff who said that those meals which are completely untouched are returned to the kitchen and offered again at teatime. It was highlighted that this is not the case for those people who eat a couple of mouthfuls. There is also no current expectation that staff offer an alternative meal at the point of refusal or try offering something at a different time. This was raised with the Manager who agreed that further consideration in respect of this issue is needed and as such a requirement has been made in this report. It has been identified at previous inspections that the home does not offer a programme of activities. Since the last inspection, it was evident that some progress has been made in respect of this issue. As such, there was documentary evidence of weekly visits by an entertainer who provides a music and sing along session. The records showed that during the most recent session, thirteen of the twenty people living at the home participated and enjoyed this activity. Feedback from those people spoken with also confirmed that they looked forward to the sing along. In addition, external people also visit on a fortnightly basis to offer a gentle exercise class and again this was reported by residents and staff to be well received. The records showed that other daily activities are provided by care staff in the afternoons. Activities such as bingo, word games and films are arranged on an ad hoc, rather than planned basis. It was also identified that there are no current opportunities for residents to go out. One resident told the Inspector that they had not been out for ages and said I would like to go to the shops. The Inspectors observed and the Manager agreed that at the current time, staffing levels would not be able to facilitate such outings. The new care plans have begun to consider peoples individual interests and social needs. Two of the residents whose care was tracked were identified as being Christians and there was evidence that the home had arranged a church service to take place in the home. Much more work however is needed to identify peoples social needs and choices and how these can be met must then be put into practice. A requirement has therefore been made that residents have the opportunity to participate in regular activities that are meaningful and individual to them. Residents are encouraged and supported to maintain contact with their family and friends. The home operates an open door policy and residents are able to spend time with their guests in their rooms or in one of the lounges. Visitors The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 16 were observed being welcomed into the home during the inspection. The Inspectors met with three visitors during their visit and they all confirmed that they can just drop in at any time and that they are always made to feel welcome. The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are now protected by the systems in place to protect them from harm. EVIDENCE: The Shires has a complaints policy which is accessible to both residents and visitors to the home. Neither the home nor the Commission have received any formal complaints about the services provided at this home in the last 12 months. The feedback received from the visitors that were spoken with, confirmed that people know how to complain and stated that if they had any concerns they would not hesitate to speak with either the Manager or the Deputy Manager. The Shires also maintains a collection of compliments that they have received and the Inspector saw that the home have received a recent letter thanking the home for the support they provide to residents. The staff spoken with were knowledgeable about the vulnerability of residents and the systems in place to protect them. Staff have received recent training in the safeguarding of vulnerable adults and prevention of abuse. It was The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 18 highlighted that the home have significantly improved in the way they deal with and report any incidents that occur between residents. The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a safe, well maintained and homely environment. EVIDENCE: The Shires is an attractive, detached property located in a residential area of Eastbourne. The home is situated over two floors, with a stair lift providing level access. A partial tour of the home identified that rooms are well decorated and furnished to a good standard. Residents are encouraged and supported to personalise their rooms and relatives spoken with confirmed that residents are able to bring items of their own furniture to the home. The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 20 Communal areas provide residents with a choice of places to spend their time. It was evident that there is now a refurbishment and maintenance programme in place and that the requirements highlighted in the previous inspection report have now been complied with. The Manager has identified other environmental improvements and the Provider has indicated in his Regulation 26 reports that he intends to action these. The parts of the home viewed, were found to be clean and tidy at the time of the inspection. The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are supported by a committed team of staff and are protected by the recruitment systems in place. Outcomes would be further improved if there were more staff to enable residents to lead lifestyles that reflect their individual needs and expectations. Continued investment in training is necessary to ensure all staff are confident and competent to undertake their roles. EVIDENCE: Staffing levels were considered inadequate at the time of the last inspection. The new Manager has reviewed the number of staff required in line with the revised plans of care. As such, staffing levels have now been increased to five care staff in the morning and four care staff in the afternoon, until 4:30pm. Between 4:30pm and 8pm there are three care staff and one general assistant. At 8pm there are two waking night staff and the general assistant who supervises people in the lounge until 10pm. The Inspectors view during the inspection was that people were being supported in an appropriate and timely way, but observed during the busy morning period that residents were left unattended in the lounge at times. At The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 22 one point in the morning, one of the Inspectors was the only non-resident in the lounge and had to intervene to prevent the escalation of a conflict between two residents which staff presence could have prevented. Feedback from two visitors highlighted that staff are respectful, friendly and caring, but they also stated that in their view, staff do not always have sufficient time to do everything that is needed. Discussion with the Manager identified that according to care plans assessment of needs and the residential staffing tool, current levels were minimum, but all parties agreed that in order to deliver choice and a more meaningful programme of activities, these would need to be increased. Staff training is ongoing and the Manager reported in their Annual Quality Assurance Assessment dated 27/02/09, that eight of the seventeen care staff employed have completed National Vocational Qualifications (NVQ) to at least Level 2 in Care. The Registered Provider also confirmed in his Regulation 26 report for April 2009 that all new staff now complete an induction and that the new programme is in line with Skills for Care. The Manager has now devised a training matrix and whilst there are still a number of gaps in staff training records, it was evident that staff have recently undertaken a number of mandatory training courses including safeguarding, fire safety and infection control. It was also possible to evidence that other courses have been scheduled. Conversation with a new member of staff confirmed that there is now an induction programme in place. It is imperative that this commitment to staff training is ongoing and as such a new requirement has been made that all staff complete regular mandatory and specialist training to enable them to keep their skills and knowledge up to date. It was a requirement of the last inspection that all new staff are employed subject to robust procedures which include a complete application form, two written references and appropriate checks with the Criminal Records Bureau. The Manager advised that he has completely overhauled the previous system of staff records. The recruitment files for two new staff were inspected and there was documentary evidence of the required information and checks being place. The Manager has now implemented a system if regular formal supervision sessions with staff. The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The recent employment of an experienced and committed Manager has served to crisis manage this service. In order to secure good outcomes the home must now seek to achieve a period of stability and concentrate on future development. EVIDENCE: The Manager has only been in post for three months. He is a skilled and experienced practitioner and has recently completed the registration process. The Deputy Manager has worked at The Shires for many years and has an excellent knowledge of the needs of the people living at the home. It is The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 24 evident that the respective skills, knowledge and experience of both of these two individuals compliment each other well and together they have been able to move the service out of the Commissions enforcement pathways. The current Manager is the seventh to have been appointed since 2005 and his current commitment to the service finally provides some stability and leadership to the management of this home. The foundations of good practice that have now been laid, need to be built upon and the service now needs to focus on development as opposed to crisis management. A robust system of quality assurance needs to be developed and meaningful ways of gaining feedback from residents and other stakeholders must be implemented. There was evidence that some residents questionnaires have been used in the past, but the Manager and the Inspector agreed that the format of these were not accessible to the people using the service and as such the information was very limited. Two regular visitors who were spoken with also confirmed that they had never been asked to provide their opinions about the service. The Manager confirmed that the home has a number of systems in place to ensure the health and safety of the home is monitored and maintained and the dates of most recent checks were included in the Annual Quality Assurance Assessment. The Inspector viewed a limited number of records pertaining to the maintenance of equipment and routine testing which were found to be satisfactorily completed. The Shires DS0000067518.V375519.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 Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 1 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X X 2 X 3 The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 26 NO 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 OP1 Regulation 6(a) Requirement Timescale for action 01/07/09 2. OP7 15(1)&(2) 3. OP9 13(2) The Registered Person must review the Statement of Purpose and Service User Guide to ensure the information contained is accurate and current. The Registered Person must 01/07/09 ensure that the newly devised plans of care are fully implemented as working documents, made available to service users and kept under regular review. The Registered Person must 01/07/09 devise a medication care plan for each service users that outlines the criteria to use medicines prescribed for only when needed. The Registered Person must consult with service users about an individual programme of activities that meets their social needs and expectations. The Registered Person must ensure that food and drinks are made available at such times as may reasonably be required by service users. The Registered Person must DS0000067518.V375519.R01.S.doc 4. OP12 16(2)(m) &(n) 01/07/09 5. OP15 16(2)(i) 01/07/09 6. OP27 18(1)(a) 01/07/09 Page 27 The Shires Version 5.2 7. OP30 18(1)(c)(i ) review staffing levels on completion of the activity programmes to ensure that there are sufficient staff on duty at all times to meet service users social and welfare needs. The Registered Person must 01/07/09 ensure that staff undertake regular mandatory and specialist training appropriate to they work they perform. The Registered Person must devise a system for monitoring and improving the service provided. This must also include consultation with service users and their representatives. 01/07/09 8. OP33 24(1) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Shires DS0000067518.V375519.R01.S.doc Version 5.2 Page 28 Care Quality Commission Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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