Inspection on 28/02/06 for The Shires

This inspection was carried out on 28th February 2006.

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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Shires 19/01/07

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 S J Bromige Unannounced Inspection 28th February 2006 11:30 Shires The DS0000027691.V285193.R01.S.doc Version 5.1 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.V285193.R01.S.doc Version 5.1 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.V285193.R01.S.doc Version 5.1 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 Alan 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.V285193.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th September 2005 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. In the past this has been an accepted arrangement, but may be reconsidered as demands of any of these services alter. Shires The DS0000027691.V285193.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place between the hours of 11.30 – 14.30 hrs on the 28th February 2006. The focus of the inspection was to follow up the requirements from the last inspection. Parts of the premises and some records were inspected. Staff and residents were spoken with. The manager was not at the Home for the majority of the time of the inspection, but came to the Home when contacted. The Commission have not received any complaints about this service since the last inspection. What the service does well: What has improved since the last inspection? The organisation has reviewed the Homes policy and procedures for the management of residents’ monies and a copy has been submitted to the Commission. Shires The DS0000027691.V285193.R01.S.doc Version 5.1 Page 6 The standard of hygiene in the kitchenette was satisfactory and residents are individually supported by staff on the importance of good hygiene. The responsible person is carrying out unannounced monthly visits to the Home and a report is being sent to the Commission. An automatic door system has been fitted to an identified bedroom door to enable it to be automatically unlocked in case of fire as this room is a designated fire exit route. All residents will be issued with revised contracts in April of each year to include a copy of the Homes revised Service User guide. Training for staff in adult protection is programmed to take place in May 2006. The edges of the floor in an identified bathroom have been sealed. upstairs bathroom has been redecorated. The All policies and procedures have been reviewed since the last inspection. All staff will be given individual folders containing all of the policies and procedures. This is good practice. 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. Shires The DS0000027691.V285193.R01.S.doc Version 5.1 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.V285193.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards have been fully assessed during this visit. EVIDENCE: Shires The DS0000027691.V285193.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards have been fully assessed during this visit. EVIDENCE: Shires The DS0000027691.V285193.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards have been fully assessed during this visit. EVIDENCE: Shires The DS0000027691.V285193.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards have been fully assessed during this visit. EVIDENCE: Shires The DS0000027691.V285193.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards have been fully assessed during this visit. EVIDENCE: Shires The DS0000027691.V285193.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards have been fully assessed during this visit. EVIDENCE: Shires The DS0000027691.V285193.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards have been fully assessed during this visit. EVIDENCE: Shires The DS0000027691.V285193.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards have been fully assessed during this visit. EVIDENCE: Shires The DS0000027691.V285193.R01.S.doc Version 5.1 Page 16 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 X 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 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X X X X X X X Shires The DS0000027691.V285193.R01.S.doc Version 5.1 Page 17 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 2 3 Standard YA20 YA20 YA20 Regulation 13 13 13 17 Requirement The allergy box on the medication chart must be filled in when charts are written. Codes must be used if medication is omitted or refused by residents The temperature in the medicine storage area must be monitored and documented daily and action taken to ensure medicines are not stored above 25°C. The temperature in medicine fridges to be maintained in the range 28°C. 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. Timescale for action 11/03/06 11/03/06 11/03/06 4 YA42 13 03/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Shires The DS0000027691.V285193.R01.S.doc Version 5.1 Page 18 No. 1 Refer to Standard YA33 Good Practice Recommendations The staff rota should include the times when the registered manager is in the home. Shires The DS0000027691.V285193.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Hereford Office 178 Widemarsh St Hereford Herefordshire HR4 9HN National Enquiry Line: 0845 015 0120 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.V285193.R01.S.doc Version 5.1 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!