CARE HOME ADULTS 18-65
Shirebrook Fields Nursing Home Spa Lane Woodhouse Sheffield South Yorkshire S13 7PG Lead Inspector
Shirley Samuels Key Unannounced Inspection 17th May 2006 09:00 Shirebrook Fields Nursing Home DS0000021807.V294596.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 Shirebrook Fields Nursing Home DS0000021807.V294596.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. Shirebrook Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Shirebrook Fields Nursing Home Address Spa Lane Woodhouse Sheffield South Yorkshire S13 7PG 0114 269 1144 0114 269 1133 sharonradford@shirebrookcaregroup.co.uk None Shirebrook Nursing Home Ltd 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) Mrs Sharon Radford Care Home 46 Category(ies) of Learning disability (46) registration, with number of places Shirebrook Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. 5. 6. The minimum staffing levels are agreed as proposed by Sharon Radford, Registered Manager, on 14th November 2005. This registration includes 10 nursing places at The Willows. This registration includes 6 nursing places at The Poplars. This registration includes 10 residential places at The Ferns. This registration includes 10 residential places at The Limes. This registration includes 10 respite places at The Acorns. The new extension of The Acorns (Respite Service) can be opened for five existing service users at any one time. No new admissions will be made onto The Acorns (Respite Service) until agreement with the CSCI has been reached. 21st September 2005 Date of last inspection Brief Description of the Service: Shirebrook Fields is a care home providing residential and nursing care for up to forty-six service users who have a learning disability. Service users have differing levels of learning and physical abilities. The home is divided into five units, two of which provide nursing care for up to sixteen service users. Three units provide personal care for up to thirty service users on a long term, short term and respite basis. The home is owned by Shirebrook Nursing Homes Ltd. Shirebrook Fields is situated in the village of Woodhouse, Sheffield, and is close to public transport and shops. All the home’s bedrooms are single with an ensuite. The home is a large single storey modern building, which includes a day centre. The home has individual garden areas for each unit and two car parks. The manager stated that the fees started at £785 for residential care and £900 for nursing care. There were additional charges for extra staff to support one to one support for some service users. Additional charges were also made for hairdressing chiropody, papers, some activities, transport, holidays and toiletries. The manager said that written information is provided to service users and their relatives in the form of a service user guide, notices around the home, service user meetings, and word of mouth. The manager added that information was available on tape, and in large. Shirebrook Fields Nursing Home DS0000021807.V294596.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 carried out over 8 hours, from 8:30am4:30 pm. Before the inspection the manager provided written information about the home, giving details about the improvements and changes to the building, policies and procedures, service users, staffing and professional visitors. Information about, accidents, complaints, service users care plans and medications were some of the records checked on the inspection. As part of the inspection, seven service users, fourteen staff, the registered manager, one professionals visitor and five relatives were spoken to about the service and the standard of care. An inspection of the building was made to make a judgement about the standard of the environment and the improvements since the last inspection. Observations were made of the care provided to service users, the approach and attitude of staff and the organisation and routines within the home. There were 10 vacant beds at the time of the inspection. Since the inspection on 21/9/05 two additional inspections have been carried out. 17/12/05 to check on issues raised in an anonymous complaint received at the Commission For Social Care Inspection office on the 16/12/05. 7/2/06 to check on the progress made on the requirements made following the inspections dated 21/9/05 and 17/12/05. What the service does well:
Assessments were obtained for service users prior to them moving into the home. Each service user had a care plan, which detailed their basic needs the level of support needed and the action the staff needed to take. Service users said they were able to make up their own mind about what they wanted to do and that the staff supported them. Risk assessments, which detailed risks to service users and the action staff needed to take to keep service users from being hurt, were in place. Some service users were being encouraged to be more independent and were being helped to develop their daily living skills, such as making drinks, cooking and cleaning. Service users were in the main helped to take part in activities, and were very much a part of the local community. Service users were encouraged to keep in contact with family and friends. Relatives said they were always made welcome when they visited and that service users rights were respected. Service users said they were “happy”, they “liked the food”, “there was a choice” and they “never went hungry”. None of the service users administered their own medication. The procedures in place did in the main meet the standards and protected service users from harm. Service users said if they were ill the staff called the doctor and there were records of appointments with other health care professionals. There are procedures in place for making complaints service users said they “would talk to staff are relatives if they were unhappy”. There were procedures in place to protect service users from harm and for responding to allegations of abuse or neglect. The environment was in the main, homely, comfortable safe,
Shirebrook Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 Page 6 clean and hygienic. Relatives and professional visitors said the staff were competent and carried out their job in the way they would expect. Service users had a main support worker whose responsibility it was to make sure that arrangements were in place to meet individuals’ needs. The layout of the unit allowed service users to access all appropriate areas. Equipment including wheelchairs, hoist, walking frames allowed service users who were independent to mobilise independently. Special chairs and beds, ensured service users comfort and dignity. Staff were observed communicating at various levels which included the use of pictures to ensure understanding. All the appropriate checks were carried out on staff before they started work at the home. Service users, relatives and staff said, “The home is well run”. Staff understood their responsibilities for making sure the environment and work practices are safe for both service users and staff. What has improved since the last inspection? What they could do better:
Full needs assessments were not kept on file for one of the service users checked. Further development is needed of the care plans. The programme of developing independent living skills needs to be extended to all service users. Where there are difficulties obtaining GP visits this needs to be addressed though appropriate channels to ensure that service users are not placed at risk. All next of kin should be notified of the changing health needs and accidents involving a service user. Concerns were received about the lack of supervision of service users, staff attitude and inappropriate behaviour and health and safety issues regarding the environment during renovation. In
Shirebrook Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 Page 7 areas of the building where risks are identified, assessments must be completed and appropriate action taken to make the building as safe as possible. Staff must receive additional training that will help them to support service users better and update their understanding of up to date good practice in the care of people with learning disabilities. Staff should receive supervision in a way that allows them to formally discuss their responsibilities, training needs and to comment on the quality of the service. Service users and their relatives must be asked what they think of the service and action taken to take account of what they have said. 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. Shirebrook Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 Page 8 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 Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 Page 9 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): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users were not admitted to the home without first having their needs assessed. This ensured that staff had the information they needed to make a judgement about the appropriateness of the placement. EVIDENCE: Two of the three-service user files checked contained a copy of the assessment carried out by a social worker prior to admission to the home. Service users and relatives said they were consulted at the point of assessment and felt aspirations and needs were included in the information submitted to the home. Shirebrook Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Care plans were in place, which identified service user needs and were reviewed regularly. This ensured that service users changing needs were assessed. Staff provided service users with information, assistance and support, which enabled them to make decisions about their own lives. Risk assessments were in place and action was taken to minimise identified risk. This allowed staff in the main to support service users to take appropriate risk as part of an independent lifestyle. EVIDENCE: There has been a review of the care plan format since the last inspection. Work is in progress to standardise the format and to ensure that all staff are aware of what, where and how information must be recorded. Care plans contained details of service users health, personal and social care needs and the action staff needed to take to meet needs. Details were recorded regarding the management of challenging behaviour. Service users and relatives knew what a care plan was and said they had contributed.
Shirebrook Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 Page 11 Further development of care plans would ensure that needs were identified and care provided with a person centred planning approach. Staff provided service users with information and assistance, which helped them to make decisions. Service users said, “We can please ourselves what we do”. Staff were observed giving service users choices and encouraging individuals to make decisions. Appropriate records were kept of service users finances, income and expenditure and receipts for purchases were checked and correct. Service users monies were pooled and not stored separately. Each service users file contained risk assessments regarding various activities. The risk and the action staff needed to take to reduce the risk was recorded. There were service users who were able to go out of the home independently. Risk assessments were in place for these individuals and the manager said there were clear procedures in place for monitoring and reporting any unexplained absences or missing person. There was evidence to show that this procedure had been used successfully. Shirebrook Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17. Quality in this outcome area is good, with further development necessary regarding service user development and organisation of staff. This judgement has been made using available evidence including a visit to the service. Service users and their relatives were provided with information about educational and occupational programmes; this allowed service users to make choices about what activities to take part in. Staff supported some service users to use the facilities in the local area, resulting in service users becoming part of the community. Relatives and friends were made welcome when they visited this made service users happy and promoted ongoing contact. In the main, daily routines at the home promoted independence, individual choice and freedom, this promoted service users rights. Service users nutritional needs were assessed and reviewed, this ensured they were provided with a healthy diet and meals, which they enjoyed. Shirebrook Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 Page 13 EVIDENCE: The manager and staff said that some service users had the opportunity to participate in and develop independent living skills. Service users on one of the units prepared meals, made drinks and assisted with housekeeping tasks. The service users and relatives spoken to said this was positive. Observations of the service users carrying out tasks, they were enthusiastic and enjoyed what they were doing. This however could be extended to varying degrees for other service users in other parts of the home. There was evidence that some service users had planned activity rotas. When asked about activities service users said, “ I go jogging round Woodhouse” “ I exercise” “we go swimming” “ we are going on holiday to Spain”. Staff said they supported service users to use the local pubs, shops and parks. Activities were taking place, including music groups, handy craft and painting. There were two activities coordinators employed at the home. Due to the level of supervision needed for some individuals the quality and positive outcome of the activity for the service users was sometimes limited. This was due (according to some staff) to the lack of commitment on the part of some staff and poor planning of the daily routine. Staff commented that the budget for activities was insufficient and that constant fundraising was essential. The relatives spoken to said, they were always made welcome and their involvement in daily routines and the lives of the service user was encouraged and welcomed. Service user said “we like the food” “there is always a choice” “we never go hungry”. Each unit had a small kitchen were snacks could be prepared. Where it was safe to do so service uses were observed making drinks. On one of the units staff said that service users helped to prepare some of the meals. Staff commented that the lunchtime menu was repetitive and the quality of the food poor. Shirebrook Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There was a mix of male and female staff working at the home this ensured that in the main service users were able to receive personal support in a way they prefer. Service users were supported to attend health appointments and staff monitored their health. This promoted good physical and emotional health. There were policies and procedures in place for the safe administration and storage of medication, ensuring that service users were protected. EVIDENCE: Service users said they were “happy with the staff who helped them”. Relatives said the staff were “caring and attentive”. Where needed, staff provided guidance and support regarding personal hygiene. There was evidence in service users files that additional specialist support and advice was obtained and action taken to implement practise to improve the quality of life for the service users. Relatives said they were consulted about the needs of service users and gave advice about how best to support individuals. They also said “The care is excellent”, “very good”, “plenty of meetings and opportunity
Shirebrook Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 Page 15 to discuss” “ staff always sort out problems quickly”, “ I am kept informed of health care needs and changes”. One relative said “there had been some problems with dental appointments in the past but it is better now”. In the main relaitives were satisfied that service users received medical attention when they needed it. The staff said there was an issue with one of the GP’s linked to the home who would not always attend and make visits to see service users when a request was made. The manager said this was being raised with the appropriate authorities. Staff said they monitored service users health and reported any complication to the appropriate specialist. One relative said they would like the home to notify them if service user had a fall our seizure. There were no service users who administered their own medication. Staff who administered medication were trained. Medication was appropriately stored and records of administration were correctly signed. Shirebrook Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users said if they were unhappy they would have someone to talk to. This ensured that their views were listened to and acted upon. There was a policy and procedures in place for the reporting of allegations. This ensured that service users were protected from neglect or abuse and that prompt action was taken if an allegation was made. EVIDENCE: The homes records show that they have received 16 concerns since the last inspection. Details of the concerns, the outcome and the action taken were appropriately recorded. There have been 4 complaints made directly to the Commission for Social Care Inspection and 2 made to the social services out of hour’s duty team. Concerns were received about the lack of supervision of service users, staff attitude and inappropriate behaviour. Health and safety issues regarding the environment during renovation. An unannounced inspection was carried out on 17/12/05 and issues were found regarding the safety of the building. The manager was served with immediate requirements to address the issues. The manager was required to investigate the issues raised regarding staff and appropriate action was taken to ensure the safety of service users. Where appropriate complaints were referred to the social services adult protection team. Since the last inspection one referral has been made the issues raised were upheld. Action was taken to resolve the problem including
Shirebrook Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 Page 17 a review of staff deployment and additional monitoring by the organisation purchasing services. The majority of staff had received training on adult protection. Staff spoken to were able to say what action they would take if an allegation of abuse was reported to them. There was evidence that the manager followed procedures and took appropriate action to protect service users from harm. Shirebrook Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. All areas of the home were accessible to service users, furniture fittings and equipment was in good condition. This ensured that service users lived in comfortable and safe environment. There were sufficient staff employed and equipment provided to ensure that the building was clean and hygienic. EVIDENCE: Since the last inspection refurbishment, decoration and replacement of furniture has taken place. Each unit has a conservatory or pleasant sittings space looking out onto enclosed gardens. Service users said they were “happy with their bedrooms”. Bedrooms were in the main personalised except for one bedroom, which was very sparsely furnished, the reasons for this were recoded in the service user file and the manager said the bedroom was regularly decorated. The decoration of personal and communal space was ongoing. Additional toilets and bathing areas were being created some kitchenettes were being refurbished while others had been completed. There was a fire exit leading onto an area were building work was taking place. There was a possible risk in terms of safe exit from the building, and the risk of service
Shirebrook Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 Page 19 users exiting the building without being detected. Reconstruction of the old gym was also taking place, the door to this area was unlocked and accessible to service users this posed a potential risk. Service users and relatives said the home was clean. Some service users were observed tidying round and making their beds as part of developing independent living skills. Shirebrook Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36. Quality in this outcome area is adequate, with further development needed. This judgement has been made using available evidence including a visit to the service. Staff who had qualification and who had received some training to carry out their jobs were supporting service users. This ensured that in the main service users were supported by competent and qualified staff Staff meetings were held but the majority of staff spoken to said they were not receiving supervision, they added that staff moral was better, this resulted in them working better as a team. The recruitment procedures included all the checks required by the regulations and the homes policy. This ensured that service users were protected. EVIDENCE: The manager said care staff received ongoing training and 48 were trained to NVQ level two in care. The manager added that a further 15 staff have been registered to commence the NVQ 2 training. future training included, Makaton, first aid, management development, infection control and Learning Disability Award Framework.
Shirebrook Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 Page 21 Four weeks staffing rotas were checked, Staff said on the majority of shifts there were sufficient staff to meet the needs of the service users. The staffing levels agreed at the time of registration were being maintained. Reviews have taken place regarding the one to one care required for individual service users and issues have been resolved, but will require monitoring. Three staff files were checked they included all the information required by the regulations including references criminal records bureau checks and employment history. Staff said they were not receiving regular supervisions. Shirebrook Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The manager has introduced leadership and structure and is, qualified and competent. This ensured that service users benefited from a well run home. There was little evidence to show that the views of service users were actively sort. This indicated that service users views did not underpin monitoring and review of the service. Staff understood their responsibilities for maintaining a safe environment for service users and staff. This ensured that the health safety and welfare of service users were promoted. EVIDENCE: There has been significant improvement in the management arrangements. Clear leadership, structure and monitoring of standards have resulted in improvement to the quality of life for the service users. Shirebrook Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 Page 23 Most of the staff spoke positively about the manager and said that staff moral was better. Some staff however, said they “did not always feel appreciated”. Reports on the conduct of the home, service user and staff views were not completed or available for inspection. Staff received appropriate health and safety, moving and handling training. Staff were observed using appropriate moving and handling techniques and hazardous substances were stored in line with risk assessments. An inspection of the building was made by the South Yorkshire Fire and Rescue service, a number of requirements were made action is being taken to comply with the requirements. The records showed that some staff had not received fire training at the required frequency. Shirebrook Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 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 2 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 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 3 34 3 35 2 36 2 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 2 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 3 x 2 x x 2 x Shirebrook Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 YA2 Regulation 12 Requirement A copy of the full needs assessment carried out prior to admission to the home must be kept on each service user file. Care plans must be further developed in line with a person centred planning approach. Support must be extended to all service users to ensure wherever possible, that there is an equal opportunity for personal development including independent living skills. Staffing must be organised in a way that allows the appropriate levels of support and supervision needed. To ensure that service users are able to engage in the activities provided. The manager must continue to pursue the issue of the GP who will not always attend when a request is made. And if necessary seek an alternatives GP. Following consultation with the service users and their next of kin relatives must be notified of any accidents or health issues. A risk assessment must be
DS0000021807.V294596.R01.S.doc Timescale for action 01/07/06 2 3 YA6 YA11 13 16 01/12/06 01/07/06 4 YA14 18 01/07/06 5 YA19 13 01/07/06 6 YA19 12 01/07/06 7 YA24 23 01/07/06
Page 26 Shirebrook Fields Nursing Home Version 5.1 8 YA24 23 9 10 YA32 YA35 18 18 competed for the fire exit leading out, where building work is ongoing. The risk assessment must also consider the risk of service users exiting the building in this area without being detected. To reduce the risk of harm to 01/07/06 service users the doors leading to any areas where construction is taking place must be kept locked. Previous timescale 19/12/05 not meet 50 of care staff must be 01/12/06 trained to NVQ level 2 in care. All appropriate staff must be 01/12/06 offered the opportunity to complete the LDAF induction and foundation training (previous time scale 16/6/04 and 31/12/05 not met). The staff must be appropriately supervised to carry out their duties (previous timescale 16/6/04 and 31/12/05 not met). 01/07/06 11 YA36 18 12 YA39 24 An effective quality assurance/ 01/07/06 quality audit system must be developed and maintained. They must be based on seeking the views of service users and relatives (Previous timescale 16/6/04 and 31/3/06 not met) 13 YA39 24 14 YA42 The responsible individual must 01/07/06 carry out visits to monitor the conduct of the home. A report must be completed and available for inspection, or submitted to the Commission for Social Care Inspection on request. 12, 13, 23 Appropriate action must be 01/07/06 taken to ensure the service users
DS0000021807.V294596.R01.S.doc Version 5.1 Page 27 Shirebrook Fields Nursing Home health, safety and welfare is promoted and protected. Therefore all staff must receive fire instruction twice yearly. All the recommendations made by the South Yorkshire Fire and Rescue service must be complied with. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA7 YA16 YA17 Good Practice Recommendations Service users monies should be stored for individuals and not pooled together. The budget for activities should be reviewed. The lunchtime menu should be reviewed. Shirebrook Fields Nursing Home DS0000021807.V294596.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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