Care Home: Shirebrook Views

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What the care home does well The home is set in very pleasant surroundings, there is a very good atmosphere and care staff have built good relationships with the people who live at the home. Care staff were very friendly and responded to and supported the people who live there. Especially to the people who have limited verbal communication skills. The home provides a good choice in meals. Several of the people are very independent and the home encourages their independent life style. This is being developed further with the implementation of more life skills into the care plan. What has improved since the last inspection? Some refurbishment of the home has taken place, a summer house complete with dinning room has been built. There is now a registered manager in place however they are on maternity leave and the Registered Provider has appointed an acting manger to cover. Staff are able to access more training. The home is developing its care plans. People have access to Advocacy services. People have been on holiday and were possible attend the local day centre. What the care home could do better: The refurbishment must take priority and be completed within the time line given. This is to ensure that people who live there have full access to the home and its faculties. Key inspection report CARE HOME ADULTS 18-65 Shirebrook Views 22 Wellington Street Matlock Derbyshire DE4 3JP Lead Inspector Nancy Bradley Key Unannounced Inspection 9th September 2009 09:00 Shirebrook Views DS0000068253.V377181.R01.S.doc 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 home adults 18-65 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. Shirebrook Views DS0000068253.V377181.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 Shirebrook Views DS0000068253.V377181.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shirebrook Views Address 22 Wellington Street Matlock Derbyshire DE4 3JP 01629 55662 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Shirebrook Care Limited Eleanor Jane Westwood Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Shirebrook Views DS0000068253.V377181.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Provider may provide the following category of service only: Care home - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Learning disability - Code (LD) The maximum number of service users who can be accommodated is: 14 2nd September 2008 2. Date of last inspection Brief Description of the Service: Shirebrook Views is a care home providing accommodation and personal care for eleven people with a learning disability. The accommodation is in a twostorey building, which has been adapted from a large house. There is a garden and a paved patio area with seating, and there are views over the town of Matlock and the surrounding area. Peoples’ bedrooms are situated on the ground and second floors. There is a stair lift from the main entrance level to the ground floor. The home is not equipped with a lift and as such, the second floor accommodation is not suitable for people with significant mobility difficulties. The ground floor has two shared bedrooms, a single bedroom and a bathroom. The second floor has six single bedrooms, a bathroom and a separate toilet. The previous inspection report is on display in the entrance area of the home. The manager did not have information on current fees as this is dealt with by head office. Shirebrook Views DS0000068253.V377181.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. This was an unannounced key inspection and took place over a total of six hours. We spoke with the people living at the home, the Responsible Individual and care staff. The Registered Manager is on maternity leave for a year and Shirebrook Care Group Ltd has appointed a manager to cover her leave. On the day we visited the manager was on holiday 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. As shown in the management section the AQAA provided little information about the home. Two people living at the home were 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. Additionally, time was spent in preparation for the visit, looking at the service history and the previous inspection report. Records were examined relating to the people living there and the general running of the home. We joined people from the home for lunch. There were ten people living at the home on the day of the visit, although they are registered for fourteen. We received ten completed questionnaires; care staff had assisted the people in completing these. The people indicated that they were happy at the home. Several of the people indicate they did not understand the questions with the majority of the answers being ticks. We received seven completed questionnaires from staff who indicated they were happy working at the home and found the acting manager supportive and always makes time to discuss issues. Majority of the staff stated “staff morale” was very high. We have received four completed questionnaires from relatives all stating they were extremely satisfied with the home, staff and they service they provide. Shirebrook Views DS0000068253.V377181.R01.S.doc Version 5.2 Page 6 What the service 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. Shirebrook Views DS0000068253.V377181.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shirebrook Views DS0000068253.V377181.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. 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. Arrangements are in place to ensure that peoples’ needs are fully assessed prior to admission and are reviewed at regularly. This will ensure that people’s holistic needs will be appropriately met. EVIDENCE: There have not been any new admissions to the care home since the last site visit. The majority of the people living at the home have been there for a number of years and have remainder there following the change of ownership in 2006. The majority of the people who were 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. The home also undertakes its own individual comprehensive needs assessment and which is in accordance with Shirebrook Care Ltd assessment process and the National Minimum Standard 2.3. The assessment then forms part of the care plan compiled by the home. Shirebrook Views DS0000068253.V377181.R01.S.doc Version 5.2 Page 9 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 living at the home have received regular visits from Care Managers within the last six months. There was evidence on file to show that the care needs assessments for people are being reviewed by the referring agency. Several of the people spoke with recalled coming to have a look around the home before coming to live there. The home has four vacancies at the time of this site visit. Shirebrook Views DS0000068253.V377181.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. 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. Inconsistencies in the care planning system and recording may compromise service delivery. EVIDENCE: During the site visit care plans of two people living at the home were viewed. The registered manager is compiling the care plans for each person who lives at the home and there was evidence of these being evaluated monthly. There was evidence of care plans being formally reviewed on a six monthly basis. Discussions with people living at the home confirmed that they knew about their care plans and were involved in the process. Peoples are now being involved more in the care planning process, however family, friends and/or advocates, and/or other relevant agencies were not. Care plans were being signed by people as evidence of their participation in the decision making process. Shirebrook Views DS0000068253.V377181.R01.S.doc Version 5.2 Page 11 The acting manager is looking to implement new care planning, risk assessments and individual profiles on all people at living at the home. During the site visit we were able to examine one of the new style care plans. Care plans will have a person-centred approach with an easy read format for people to understand. Daily living notes will be completed on each person by the staff on duty. This will include night staff as well. Staff also write a brief life history about each person for whom they are key worker. The information in the care plans has improved since the last site visit and they now are giving staff direction on how they are to deliver care. As discussed with the Responsible Individual there is still some inconstancies’ in care plans. The care plans once compiled are reviewed by the Responsible Individual and amended as required. As discussed at the site visit there is a number of crossing out and amendments to information which needs to be addressed. Since the previous site visit people at the home all have access to local Advocacy services. Risk assessments were in place, and indicated actions staff should take after the risk has been identified and assessed. Risk assessments did not include tissue viability, trips and activities. These need to be updated and reviewed in line with care plans. Shirebrook Views DS0000068253.V377181.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: Standards 12, 13, 15, 16 and 17. 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. There were arrangements in place to enable people at the home 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 majority of the people who live at the home attend the local day centre between three and four days a week and transport is provided. There are some other occupational type activities available for people who do not wish to attend the centre. However several of the people indicated they do not always want to take part but prefer to watch T.V. listen to the radio, have relatives to visit or go out to the shops. Care staff stated that families tend to visit more at weekends. People living at the home confirmed that their relatives are always made welcome. Several Shirebrook Views DS0000068253.V377181.R01.S.doc Version 5.2 Page 13 completed staff questionnaires stated they would like to take people out more at weekends, however transport was a problem. The home has a mini bus, but no driver. The manager has implemented a more flexible daily routine for people at the home and they are now being supported to make their own decisions about how they spend the day. People at the home talked about going on holiday to Blackpool and to Skegness. Care staff from the home have arranged holidays for the majority of the people who live there. The minister visits the home monthly for people wishing to take part in religious services. Information on records indicates that contact with family and friends are appropriate. The relationship observed between care staff and service users were open and friendly. The service users are encouraged to take pride in their appearance and their preferred style of dress is respected. Examination of the menus and discussions with the care staff indicate the home is providing a healthy well-balanced and nutritious diet. On the day we visited people were given a choice of meals; fresh fruit and drinks were available. The home has now appointed a cook. The menu is displayed and the manager has compiled an easy read format. We took lunch with the people living at the home and care staff were observed assisting people with their meal. Training records seen confirmed that all staff complete a food hygiene course. Shirebrook Views DS0000068253.V377181.R01.S.doc Version 5.2 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20. 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. People receive personal support in ways, which enables them to be independent. However inconsistencies in the administration of medication may leave people vulnerable and at risk. EVIDENCE: Several of the people living at the home are not able to express themselves verbally and to directly contribute to the visit. During the tour of the home we spoke with some people who stated they were happy at the home, the staff cared for them and that they liked it there. The people who were less able to express themselves looked relaxed and contented. Direct observations identified that the majority of the people require some assistance with personal support with several having a high level of need and support. Discussions with staff indicate that they have satisfactory insight into the needs of individual people and are committed to supporting and assisting them. Shirebrook Views DS0000068253.V377181.R01.S.doc Version 5.2 Page 15 People health was well maintained and records showed that care staff promptly contacted the appropriate medical services. Records seen indicated that all of the people have been registered with the local doctor, optician, podiatry services, dentist, and audiologist. The home monitors people’s medication, as none of them are able to do so, one person at the home has their own inhaler. The arrangements for receipt, storage, administration and disposal of medication were also examined and found to satisfactory at the time of this site visit. The AQAA indicated that only fully trained staff administer medication. However training records seen indicated several staff have yet to undertake training in administering and medication procedures. The list of staff authorised to administer medication and a copy of their signature was not accurate. Medication administration is recorded on Medication Administration Records (MAR sheets). The home has medication supplied from Boots pharmacy and an audit of medication procedures by them has been undertaken. Families of the people at the home have been contacted regarding their relatives End of Life plans. Shirebrook Views DS0000068253.V377181.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. 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. Arrangements are in place to safeguard peoples’ welfare and ensure that their concerns are listened to and acted upon EVIDENCE: Discussions with the people who live at Shirebrook Views and completed questionnaires confirmed that they were aware of the home’s complaints procedure. A copy of the home’s complaints procedure is displayed in the main hallway and is an easy to read format. Any concerns and complaints made are investigated within the agreed time scales and in line with in Shirebrook Cares policy and procedures. The manager maintains a record of all complaints made by people details of the investigation action and outcome. The procedure contains the contact details of the Care Quality Commission and informs the complainants that they are able to contact us at any stage of the complaints process if they wish to do so. People indicated they would speak with the manager, staff or their families about any concerns they had. Records seen indicated that they had received no complaints since the previous site visit. We have not received any formal complaints about is service. Shirebrook Views DS0000068253.V377181.R01.S.doc Version 5.2 Page 17 The home’s policy on Safeguarding Adults was examined. This is a corporate policy and has been updated to cover Safeguarding of Adults There have been no safeguarding incidents since the previous site visit. Training records seen confirmed that all but two staff had received training on safeguarding of vulnerable adults. The staff who had not received training were newly appointed and were scheduled in for next moth. The training is delivered by the Responsible Individual who has completed a trainer course. . People financial records were seen. There was no evidence to show a Mental Capacity Act assessment had been undertaken were Shirebrook Care Group Ltd was identified as being responsible for people finances. Information in the AQAA indicates that the people have a financial support plan and risk assessment. Shirebrook Views DS0000068253.V377181.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment is poor for people living at the home, effecting their daily lives and independence. EVIDENCE: We carried out a full tour of the home, accompanied by the Responsible Individual. All communal areas were inspected together with staff facilities. Peoples’ bedrooms were inspected with their agreement and all rooms furnished to their personal choice and wishes. Shirebrook Views provides a domestic style environment for the ten people all of which have lived at the home for three or more years. Many of the rooms had been made in to bed-sit style accommodation, where service users can meet with family and friends in private. Shirebrook Views DS0000068253.V377181.R01.S.doc Version 5.2 Page 19 The issues relating to the environment and the general condition of the building have been identified in the previous reports. The refurbishment of the building is under way. Representatives from Shirebrook Care Group Ltd, were present at the site visit and gave assurances that the work would be completed as soon as possible. Mr S Cooling Registered Provider stated the timeline for completion work would be one year. Shirebrook Care Group Ltd have built a summer house as part of the refurbishment of the home and it’s envisaged this will be open for people to use shortly. The general environment is dated and there were signs of wear and tear to furnishings and décor. Shirebrook Care Ltd have purchased new furniture for the general lounge. At present there is no cleaner working at the home and care staff are covering basic cleaning duties. The Responsible Individual stated deep cleaning would take place immediately and a team of cleaners from another home would undertake the work. There are still several area requiring attention from the pervious site visits. Paintwork yellow, dirty and is peeing off in various parts of the home. Carpet dirty and thread bear in the upstairs landing and in some communal areas. • General decoration of the house was poor. • Two bedrooms had an unpleasant odour. • Furniture in the dinning room well worn The only refurbishment, which has been undertaken, is the residential accommodation that was occupied by the previous owner. This has been converted to make three more bedrooms and formed part of the variation to the homes registration. The standard of that accommodation is very good; however the rest of the home is not to that standard. This accommodation is not in full use. The laundry has been moved and is now situated in an outhouse to the side of the home. At present the there is no emergency call system fitted to the home. Risk assessments are in place, which address the lack of an emergency call system. Several of the rooms have been fitted with a mobile intercom system. At the time of this site visit parts of the home are not accessible to the people who live there. Training records indicated all staff have yet to complete infection control training. • • Shirebrook Views DS0000068253.V377181.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,34,35,36. 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. The home has robust recruitment and selection procedures in place to ensure that the appropriate staff are employed to care for vulnerable people. EVIDENCE: The home has a high percentage of staff who hold a NVQ level 2/3 or are working towards attainting the qualification. The home has a robust recruitment procedure in place, which ensures that their staff are suitable to work with vulnerable people. Several staff personnel records were examined which confirmed that thorough employment checks had been carried out. All new staff provide two references, a full employment history, have a clear Criminal Records Bureau clearance and complete a three months probationary period. The records contained all required information has detailed in Schedule 2 of the National Minimum Standard, Care Homes for Adults 2001. The staff personnel records were well presented and organised. Shirebrook Views DS0000068253.V377181.R01.S.doc Version 5.2 Page 21 All staff receive induction training and commence comprehensive foundation training with three months of appointment. Discussions with the manager and examination of training records indicate the home is providing good training and development opportunities. Details of staff training together with training planned were provided at this site visit. The manger has compiled a training matrix showing all the training undertaken by the staff. However we noticed that staff have not undertaken an introductory course in leaning disability, training on the Mental Capacity Act and Deprivation of Liberty Safeguarding (DOLS). Discussions with the Responsible Individual and records seen confirmed that staff receive regular supervision. Shirebrook Views DS0000068253.V377181.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42. 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 home was generally well managed, with staff seeking the views of the people who live there. However the lack of robust quality assurance procedures and management system may affect the overall running of the home. EVIDENCE: Since the previous site visit the home has a registered manager in place. At present the registered manager is on maternity leave and Shirebrook Care Croup Ltd has appointed an acting manager. The AQAA indicates that Shirebrook Care Group Ltd recruit managers who are willing to, working towards or have a recognised manager award. Information Shirebrook Views DS0000068253.V377181.R01.S.doc Version 5.2 Page 23 in the AQAA is not clear as to the status of the registered manager in relation to a recognised manager award. Staff spoken with during the site visit and completed questionnaires indicates that the staff find the acting manager very supportive and that under her management staff morale is much improved. Although information in the AQAA indicates regulation 26 visits are carried out there was little evidence to support this. We have not received copies of these visits since February 2009 as requested by Care Quality Commission at the previous site visit. The last copy the home has was dated April 2009. The home has undertaken some quality assurance since the previous site visit This was undertaken in December 2008, this included questionnaires being given to staff and people who use the service. A summary is compiled and presented to the Board. Stakeholders were not consulted nor were the findings not made public. During the site visit we did speak with a family member who stated “they were happy with the care provided by the staff and the manager.” The AQAA dataset indicated that all the necessary maintenance of equipment checks had been undertaken. Shirebrook Views DS0000068253.V377181.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 3 X Version 5.2 Page 25 Shirebrook Views DS0000068253.V377181.R01.S.doc 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 YA20 Regulation 13 Requirement The home must have an up to date list of staff signatures who are authorised and assessed as competent to administer medication. This is to ensure that people are fully protected Only staff who are authorised, whose competency has been assessed and documented must be permitted to administer medication. This is to ensure people are fully protected and the homes medication procedures are followed. Timescale for action 31/10/09 2 YA20 13 31/10/09 3 YA23 14 Schedule 4 4 YA24 23 The Registered Provider must 31/10/09 have the appropriate documentation to show they are authorised to act on behalf of the people at the home and to regulate their finances. This is to ensure people are fully protected and financial procedures are maintained. The home must ensure the 31/12/09 premises are suitable for the aims and objectives as set out in the Statement of Purpose. DS0000068253.V377181.R01.S.doc Version 5.2 Page 26 Shirebrook Views 5 YA24 23 This is to ensure people live in a clean, homely and safe environment The Registered Provider must implement the refurbishment of the home as soon as possible. This is to ensure that people in the home can assess all parts of the home and live in a comfortable environment. All staff must complete training on infection control. This is to ensure people live in a clean and hygienic home. All staff must undertake training commensurate to the post they hold. This is to ensure people are cared for by a competent staff team The Registered Provider must undertake regular visits to the home and copies of these visits must be sent to the Care Quality Commission. This is to ensure the effective and efficient running of the business and to promote an open, positive atmosphere and to demonstrate leadership and management of the home. 31/12/09 6 YA30 18 31/10/09 7 YA35 18 31/10/09 8 YA39 26 31/12/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA24 YA29 Good Practice Recommendations The registered Provider should confirm in writing as to when the refurbishment will b completed. The home should install an appropriate call system. DS0000068253.V377181.R01.S.doc Version 5.2 Page 27 Shirebrook Views 3 4 5 6 YA35 YA39 YA39 YA39 All should undertake training on the Mental Capacity Act and Deprivation of Liberty Safeguarding (DOLS). Shirebrook Care Group Ltd should confirm the status of the registered manager in relation to her return to the home and a recognised manager’s award. The home should include stakeholders as part of their quality assurance monitoring. The home should make public its quality assurance findings. Shirebrook Views DS0000068253.V377181.R01.S.doc Version 5.2 Page 28 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA 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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