Care Home: Shirebrook House

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What the care home does well The home was comfortable in appearance, was maintained to a good standard and set in a residential part of the town. All of the people living at the home have their needs assessed prior to admission. The home provides a good ratio of care staff to people who live there. The people who were moved in to the home have settled well and this is to be skills and abilities of care staff. What has improved since the last inspection? Station Road House has been a dormant service since August 2008 and was recently reopened to accommodate the people from Shirebrook Manor. Station Road House was formerly known as Shirebrook House and when the group was sold to Care Aspirations is now known as Station Road House. Station Road House provides residential and nursing care for ten younger adults with learning and physical disabilities. All or the requirements from the previous inspection report have been addressed. What the care home could do better: As the home has recently reopened a period of stability is required for people who live there and the staff. The home needs to have a registered manager in place with relevant experience and knowledge to care for the people who live there. To address the requirements made in the report. All care plans need to be formally reviewed to reflect the care currently being provided. Care aspirations need to address the issue of qualified staff in relation to their NVQ level II. Key inspection report Care homes for adults (18-65 years) Name: Address: Shirebrook House 19 Station Road Borrowash Derbyshire DE72 3LG     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Nancy Bradley     Date: 2 1 0 6 2 0 1 0 This is a review of 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. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 31 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 Adults (18-65 years) 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. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 31 Information about the care home Name of care home: Address: Shirebrook House 19 Station Road Borrowash Derbyshire DE72 3LG 01332725734 01142691133 shirebrookhouse@shirebrookcaregroup.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Shirebrook Care Limited Name of registered manager (if applicable) Type of registration: Number of places registered: care home 10 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability physical disability sensory impairment Additional conditions: The maximum number of service users who can be accommodated is 10 The registered person may provide the following categories of service only: Care Home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are: Learning disability - Code LD Physical disability - Code PD Sensory Impairment - Code SI Date of last inspection Brief description of the care home The Care home is situated in the village of Borrowash, which lies on the Derbyshire and Nottingham boarder and owned by the Shirebrook Care Limited, which is a privately owned company. The home provides residential care for ten adults, whose primary needs include sensory impairment, learning and physical disabilities. The Care Homes for Adults (18-65 years) Page 4 of 31 Over 65 0 0 0 10 10 10 2 0 1 1 2 0 0 9 Brief description of the care home building is a detached house situated on a residential housing estate in Borrowash close to local amenities. The accommodation is spacious and has been adapted to meet the needs of the people who will live there. Facilities for service users are located on the ground and first floor; the staff and sleeping in room is located on the second floor. The home has ten single bedrooms with en-suite facilities; all rooms except for two rooms have shower facilities. The dining and lounge areas, kitchen, laundry and conservatory are on the ground floor. A `walk in shower room and a bathroom with a bath and tracking hoist are located on the ground floor; the three bedrooms on the first floor have en-suite shower facilities. Information on fees was not available Care Homes for Adults (18-65 years) Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. This was an unannounced key inspection and took place over a total of five hours. We spoke with the manager and care staff. The inspection activity during this site visit was to assess the service against the key National Minimum Standards and these are identified through the report. We looked at all the information that we received or asked for, since the last key inspection. This included the following: The Annual Quality Assurance Assessment (AQAA) that was sent to us by the home. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the home. Care Homes for Adults (18-65 years) Page 6 of 31 Records relating to the general running of the home were also viewed. One person at the home was case tracked. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at care plans and other documents relating to that persons care, talking to staff regarding the care they provide and if possible talking to the person. We sent out ten Have Your Say questionnaires to people living as the home, family and care staff none were returned. Care Homes for Adults (18-65 years) Page 7 of 31 What the care home does well: What has improved since the last inspection? 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. Care Homes for Adults (18-65 years) Page 8 of 31 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements are now in place to ensure that peoples needs are fully assessed prior to admission. Evidence: The home as updated its Statement of Purpose to reflect the change of ownership, its amended conditions of registration and service name. The Service User Guide was not available at the time of this site visit. The majority of the people who had been admitted to the home had their needs assessed through the care management system, which highlights their additional needs, and the need for additional staffing hours. There was evidence on file to show that the care needs assessment of the person had been reviewed by the referring agency. All of the people who moved into the home have had a 72 hour review following their admission from Shirebrook Manor. Care Homes for Adults (18-65 years) Page 10 of 31 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a care planning and review system in place, which ensures that peoples individual needs are being addressed. However the inconstancies in recording of care plans and risk assessments may affect the care people receive. Evidence: The home made the care records of the people who had lived there available to us. During this visit we viewed the care records of one person. The manager from a previous home had compiled the care plan and evidence was seen of these care plans being reviewed on a regular basis. The one person who was case-tracked had a comprehensive care plan, which was in accordance with their assessed need and formulated within a risk assessment framework. Care plans were detailed and included the persons individual lifestyle preferences and choices; the interventions prescribed by outside health care professionals were appropriate. Daily records are also maintained on each person. As discussed with the manager all of the care plans/support plans need to be formally Care Homes for Adults (18-65 years) Page 11 of 31 Evidence: reviewed and updated to reflect the change of care and the service provided. All of the care plans seen were based on the care being provided when the people living at home where living at Shirebrook Manor. People living at home had been resident there for four weeks. A more person centred care plans needs to be developed these could run alongside the more formal care planning system in operation. As discussed with the manager a more formal reviewing system needs to be implemented. People living at the home need to be aware of their care plan and this should be explained to them in a format which they can understand, agree to and sign. In some cases they may not be able to this and could be done by family, a care manager or Independent Advocate. Risk assessments were in place covering issues such as, peoples health and safety, physical health, nutrition, mobility, behaviour management and risks associated with social activities. All risk assessments require monitoring and updating in line with the care plans. The previous home had undertaken some life experience work this needs to be continued and incorporated into the care plan/support plan. Care Homes for Adults (18-65 years) Page 12 of 31 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There were arrangements in place, which enable people to maintain and develop appropriate relationships, and to participate in activities both in the home and outside in the wider community in accordance with their preferences and wishes. Evidence: The care records of one person from the home were seen and provided detailed needs assessment and care planning information regarding their social, recreational, educational and occupational activities both within the home and outside the community. Direct observation of the people living at the home indicated they were happy living there. Information in the AQAA and from discussions with the manager indicated the home provides a varied activities programme. One person records indicated they were due to go on holiday with their family. Care Homes for Adults (18-65 years) Page 13 of 31 Evidence: People at the home were likely to places or to the local day centre operated by care inspirations. Station Road House shares a minibus and driver with other homes in the group this enables them to take people out for the day. The manager the indicated that further day trips are planned. Their relationship was observed between care staff and people all over the home appeared open and good humoured. People at the home indicated they have a close relationship with staff will play an important part in their lives. The staff encourage people living at the home to take pride in their appearance in their desired dress sense is respected. The daily routines are flexible with everyone be able to make their own decisions about how they spend their day. The majority of the people who live at the home are able to work do to their level of disability. Information on peoples records indicated that contact with family and friends were appropriate. Any restrictions on contact would be recorded in care plans. People can speak freely with family and friends by telephone and receive mail. Examination of the menu show the home is providing healthy well-balanced and nutritious diet. The care staff discussed with the cook their peoples lives and dislikes and a four-week menu was compiled around their preferences. The manager indicated the home is looking to provide more options and choice within its menu. Care Homes for Adults (18-65 years) Page 14 of 31 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive personal support in ways, which enables them to be independent. However the recording and administration of medication requires further strengthening. Evidence: Discussions with staff indicate that they have satisfactory insight into the needs of individual people and were committed to supporting and assisting them. The home is recording all visits made by people at the home to the G.P.s opticians, podiatry, dentists, audiologist, and speech and language therapist. The records on peoples weight and hospital appointments are recorded and kept as part of the care plan. From records seen and from discussions with staff, peoples health and personal needs are being met . People living at the home are generally healthy and records showed that staff promptly contacted the appropriate medical services when necessary. People living at the home are registered and attended services within the community including doctor optician, podiatrist, dentist, and audiologist. The people at the home indicated they have a choice of showering or bathing daily. Care Homes for Adults (18-65 years) Page 15 of 31 Evidence: The home operates and monitors medication administered no one is able to self medicate unsupervised. Only the nursing staff who have received training on medication procedures can administer medication. The arrangements for receipt, storage, administration and disposal of medication were also examined and found to satisfactory. These included any controlled drugs administered by the home. The home has their medication supplied from the Boots pharmacy which carries out regular inspections. As discussed at the site visit the home needs to have any changes to how medication is administered agreed by the doctor, fully recorded this applies to changes made verbally following visits to the surgery. The list of signatures of staff that are authorised to administer medication requires amending and updating. The home is currently compiling end of life plans for all of the people who live at the home base is in conjunction with Placing Authorities and immediate family. Care Homes for Adults (18-65 years) Page 16 of 31 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements are in place to ensure people are listened and their concerns are acted upon. However this could be further enhanced by staff receiving training on the protection of vulnerable adults. Evidence: People living at the home are made aware of the home complaints procedure through their key worker. An easy to read copy is displayed with in the home. Any concerns and complaints made by people living at the home or their relatives are investigated within the agreed time scales. The manager maintains a record of all complaints made by people living at the home or their relatives this includes details of the investigation action and outcome. The complaints procedure contains the current contact details of the Care Quality Commission and informs the complainants that they are able to contact the Commission any stage of the complaints process if they wish to do so. We have not received any formal complaints from people or their relatives about their care since the site visit. Information in the AQAA indicates the home has not received any complaints about its service. Care Homes for Adults (18-65 years) Page 17 of 31 Evidence: Discussions with the manager and records seen indicate that there have been no incidents under safeguarding of adults procedures. The homes safeguarding adult protection policy is a corporate policy operated within Care Aspirations Limited. As discussed with the manager the policy needs to include the contact details for the local social services office and make reference to local procedures. Information from the manager and from staff training records indicates that the majority of the staff require up to date training on safeguarding vulnerable adults. The home policy on physical intervention was not seen at this site visit, the deputy manager stated that they use the Crisis Prevention Intervention Method. This requires more de-escalation techniques with physical intervention as the last resort. Records seen indicate several staff require refresher training in this area. Only staff that have up to date training on physical intervention techniques should be involved in physical intervention incidents. Peoples monies are checked regularly by the manager and provider. The Care Aspirations policy states that two signatures are required for each transaction undertaken on behalf of people at the home. On examination of peoples financial records two signatures were not being recorded when money was withdrawn by care staff. This was brought to the attention of the manager at the time of this site visit. The home has a separate policy for whistle blowing. Care Homes for Adults (18-65 years) Page 18 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The general standard of the home and the environment was good and would provide an attractive and comfortable place in which people could live in. Evidence: We carried out a partial tour of the home; the manager was present. All communal areas were inspected. The home was clean, well maintained, well furnished, equipped and well lit and heated. There is a central kitchen and separate laundry and staff facilities. All of the bedrooms are single with en-suite facilities. Blinds have been fitted to the windows which look out on to the street. The home has a conservatory and a small garden / patio area. There are no outstanding maintenance issues. The home has a working lift. The home has satisfactory hygiene procedures in place. However several staff still need to undertake training on infection control procedures. The home has a full-time cleaner and laundry person Care Homes for Adults (18-65 years) Page 19 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has recruitment and selection procedures in place to ensure that the appropriate staff are employed to care for vulnerable people. This could be further strengthened with the appropriate trained staff in place. Evidence: The home has four qualified nurses with the five care staff having a NVQ level II or working towards qualification. The manager confirmed that the majority of the staff are waiting to be signed off for their NVQ level II. The manager indicated that there are five staff with a NVQ level II and three care staff ready to commence NVQ level III. Information in the AQAA indicates the home has a robust recruitment procedure in place, which ensures that their staff are suitable to work with vulnerable people. Staff working at the home have transferred from Shirebrooke Manor enabling continuity of care. At present the home has a good skills makes and ratio of staff to people living at the home. Care Homes for Adults (18-65 years) Page 20 of 31 Evidence: Staff personnel records were examined at this site visit and contained all they required information under Schedule two regulations Care Homes for Adults 18 to 65. The managers personnel records were not available at this site visit these are held at the Companys HR department in London. The staff at the home transferred to Station Road House and are working there for the next six months. The manager stated recruitment of new staff will shortly begin as the present staff will return to The Manor after its refurbishment. The new staff will require a full induction programme before they commence their duties within the home. Care Aspirations has yet to issue new contacts to its staff, following their acquisition of the Shirebrook Care Group Ltd. From discussions with the manager and from examination of the training records several staff require refresher training in many of the mandatory areas. The Mental Capacity Act Deprivation of Liberty will need to be included in the training. Discussions with the manager and records seen confirmed a formal supervision and team meeting system has been established. Staffing rota was not easy to understand, as there were several alterations and crossings. As this discussed with the manager changes to the rota must be approved by her. Care Homes for Adults (18-65 years) Page 21 of 31 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this 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 home is generally well managed; polices and procedures in place which ensure the home is run in the best interests of the people who live there. Evidence: Since the home has been registered they have been a number of changes in manager. The only registered manager resigned in November 2007, with numerous managers having since been appointed however none have stayed or been registered with the Care Quality Commission. The most recent manager left in May 2009 having been at the home for eights months. The home has been a dormant service from August 2009 until May 2010. Shirebrook Care Group Limited was sold to Care Aspirations Limited earlier this year and a new manager was appointed. The new manager has been in post for four weeks. The new manager indicated she was interviewed and appointed for the post of manager, however she has not been given a job description showing her roles and responsibilities. Care Homes for Adults (18-65 years) Page 22 of 31 Evidence: Discussions with the manager indicated she is committed to working at the home and is looking long-term to develop the home. As the home as recently re- opened the registered provider has yet to undertake any formal quality assurance. The Quality Assurance Manager will undertake this role in line with Care Aspirations quality assurance procedures. Discussion with staff indicated that Care Aspirations Limited are making changes and addressing issues. Information in the AQAA Dataset indicates that all health and safety and maintenance of equipment checks have been undertaken prior to the home reopening. Care Homes for Adults (18-65 years) Page 23 of 31 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 24 of 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 5 A copy of the the homes Service User Guide must be available to all of the people who live there. This is to ensure people have all the information they need about where they live. 31/07/2010 2 1 6 The Care Quality 31/07/2010 Commission must be notified of any changes to the Service User Guide This is to ensure the Care Quality Commission have an update information regarding the home. 3 2 7 The Service User Guide must 31/07/2010 be in a format they can understand. This is to ensure people have the information they need about where they live. Care Homes for Adults (18-65 years) Page 25 of 31 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 4 6 15 All care plans must be relevant to the care people are receiving. This is to ensure their changing needs and personal goals are reflected in the care they receive. 24/07/2010 5 6 1 All risk assessments must be 31/07/2010 reviewed and updated to reflect changes in the care being provided. This is to ensure their changing needs and personal goals are reflected in the care they receive. 6 20 13 The list of authorised 31/07/2010 members of staff who can administer medication must be updated. This is to ensure that only staff who are trained in medication procedures can administer medication and to protect the people against medication errors. . The home must obtain fully 31/07/2010 signed agreement and instructions from the appropriate doctor before people are given medication. This is to ensure people receive the medication they 7 20 13 Care Homes for Adults (18-65 years) Page 26 of 31 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action are prescribed and to protect against errors in medication administered. 8 23 13 All staff must receive refresher training on physical intervention techniques. This is to ensure people are fully protected. 9 23 13 All staff must receive training on safeguarding vulnerable adults. 31/08/2010 31/08/2010 This is to ensure people are fully protected. 10 23 13 All staff must comply with 31/08/2010 the Companys financial procedures when withdrawing peoples monies. This is to ensure people are fully protected. 11 30 16 All staff must undertake training in infection control and procedures. This is to ensure people are fully protected. 12 32 18 The home must have sufficient numbers of care staff who hold an NVQ level II or above. 31/07/2010 31/08/2010 Care Homes for Adults (18-65 years) Page 27 of 31 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is to ensure people are supported by appropriately trained staff . 13 32 18 The home must have sufficient numbers of care staff who hold an NVQ level II or above. This is to ensure people are supported by appropriately trained staff. 14 35 18 All staff must receive additional training to assist in personal; development and to meet the individual needs of the people they care for. 31/08/2010 31/08/2010 This is to ensure people are supported by appropriately trained staff . 15 35 18 All new staff must receive structured induction training before they commence rota duties. This is to ensure people are supported by appropriately trained staff . 16 37 9 The home must have a qualified manager in place and submit their application to register the Care Quality Commission. 30/09/2010 31/07/2010 Care Homes for Adults (18-65 years) Page 28 of 31 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is to ensure the day to day running of the home. 17 39 26 The Registered Provider must undertake formal quality assurance and monitoring and provide the care Quality Commission with a copy. This is to ensure the development of the home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 30/09/2010 1 7 People living at the home should have the opportunity to sign their care plan as part of their understanding and agreement regarding the care they receive The home showed consider using my health passport booklet when taking people to the doctors also for recording or health issues. End of life plans should be complied on all of the people who live there. The homes policy on safeguarding vulnerable adults should make reference to local social services procedures. The homes policy on complaints should show the correct details for Care Quality Commission. The manager should obtain a copy of the social services safeguarding vulnerable adult procedures for the area the home is located. The manager should take responsibility for the overall Page 29 of 31 2 19 3 4 21 22 5 6 22 23 7 33 Care Homes for Adults (18-65 years) Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations management of the staffing rota. 8 35 All staff from Shirebrook Group Care Ltd should have a new employment contract showing the terms and conditions for working for Care Aspirations Limited Care Homes for Adults (18-65 years) Page 30 of 31 Helpline: 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. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. 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