CARE HOME ADULTS 18-65
Shirebrook Fields Nursing Home Spa Lane Woodhouse Sheffield S13 7PG Lead Inspector
Shelagh Murphy Announced 22 April 2005 08:10am
nd 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 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 Stationary 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. J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION
Name of service Shirebrook Fields Nursing Home Address Spa Lane Woodhouse Sheffield S12 7PG 0114 2691144 0114 2691133 None Shirebrook Nursing Home Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Vacant N Care Home with Nursing 44 Category(ies) of LD Learning disability (44) registration, with number of places J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION
Conditions of registration: 1. There are 19 LD learning disability N (Nursing Care) beds in a self contained unit. 2. There are 25 LD learning disability PC (Personal Care) beds in a self contained unit. Date of last inspection 13th January 2005 Brief Description of the Service: Shirebrook Fields is a care home providing residential and nursing care for up to forty-four service users who have a learning disability. The home is divided into five units, two of which provide nursing care for up to nineteen service users. Three units provide personal care for up to twenty-five service users. 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 and the majority of the bedrooms are en-suite. The home is a large single storey modern building, which includes a day centre. The home has a large garden area and a car park. J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Shelagh Murphy and Anne Hayselden (Regulation Manager) carried out this announced inspection over seven hours from 8:10 to 15:00. This made a combined inspection time of fourteen hours. Judith Adams, acting manager and Steve Cooling, owner of Shirebrook Nursing Homes Ltd, were present during the inspection. Opportunity was taken to make a partial tour of the premises, inspect a sample of records and policies and talk to staff and residents. The inspectors ate lunch with the residents. The inspectors had the opportunity to speak to 8 staff on duty, 1 visiting relative and 6 of the 26 residents on site. Two letters were given to the inspectors from staff who were not on duty, both detailed staff concerns about inadequate staffing levels at the home over recent months. What the service does well: What has improved since the last inspection?
Some of the residents had had their bedrooms re-decorated. These residents had chosen the colour schemes with staff support. Some communal areas of the home had also been redecorated, including kitchenettes and corridors and these made the units look much cleaner and homely. The residents said they had attended two meetings with the staff since the last inspection, at which they were able to talk about activities, holidays and food. The residents said they enjoyed these meetings.
J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 Page 6 The staff said that they had received training on adult protection, managing challenging behaviour, fire safety and infection control, they said the home had improved in this area and as a result they felt more confident in dealing with these issues. The grounds around the home had been fenced and the staff said this made them feel safer as they had previously experienced problems from local youths. A new statement of purpose had been created which clearly laid out what the service users and relatives could expect from the service. What they could do better:
A permanent manager, who is appropriately qualified and experienced, needs to be recruited. The staff complained that there was a lack of effective leadership and communication in the home. They said they found it difficult to talk to the acting manager as they felt she was unapproachable. The residents said they enjoyed going out but sometimes activities were cancelled as staff were off sick. One relative said his daughter had very few opportunities to attend external activities and there were very limited activities available in the home. Staff said that male carers had to support female residents with personal care tasks, due to staff shortages and they thought this was inappropriate. The staff said communication in the home was poor as they did not have regular staff or team meetings. The staff said that some residents care plans had not been reviewed on a regular basis. This combined with the ineffective communication meant that the staff were unsure about whether service users should be receiving 1-1 staff support and how they should work with some of the residents. Residents were not sure what they were having for lunch and the staff said they had not been given menus for the residents, this limited the residents choice of meals. Mealtimes were not planned and organised appropriately by staff. The recording systems on medicine charts needed to be improved to make sure all residents are given the medicines they are prescribed in a safe way and at the times required, and to ensure that staff sign to say they have administered medication. J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 Page 7 There were many areas in the home, including bathrooms, dining rooms and lounges, which needed redecorating and refurbishing some areas of the environment looked bare, institutional and uncared for. Many of the residents bedrooms required re-decorating and personalising as they appeared bare and uncared for, bedding in some rooms was inadequate as the pillows were lumpy and the bedding was faded and worn. Staff said they had not been regularly supervised and this had contributed to staff leaving the service and to low staff morale. Some said that because other staff were not effectively supervised they would not do their jobs properly and described some staff as “lazy”. These staff also said that some members of staff did not turn up for their shifts and this also led to staff shortages. Staff said they were unsure about who was in charge when the manager was not on duty and this led to confusion about where staff were to be deployed. All of the staff said that there were staff shortages, they said this had led to residents having fewer opportunities to get out and attend activities. They said this also caused increased stress for the staff as they needed to work extra shifts to cover the staff vacancies. The staff rosters were checked by the inspectors and during the period checked the home was operating to the minimum staffing levels agreed. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 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 standard(s) 1 and 2. The home had a statement of purpose and a service users guide. The service users guide needs reviewing. Residents had, had their needs assessed this ensured the home was suitable to meet their care needs. EVIDENCE: The statement of purpose had been reviewed and now met the regulations. The service users guide had not been reviewed and did not have up to date information contained in it. Copies of full needs assessments were contained in resident care plans. The information from the full needs assessment had been incorporated into two of the three resident care plans. J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 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 standard(s) 6, 7, 8 and 9. The contents of the residents care plans checked had improved generally, some plans needed more detailed information and one needed reviewing. Some residents, who were able to, had attended their care plan meetings. One service user still needed to have her needs re-assessed to ensure the home could meet their complex needs. There had been two residents meetings with staff since the last inspection and they had discussed activities and holidays. Staff and residents said they were not consulted on many aspects of how the home was run. Risk assessments had been devised for service users to protect them. J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 Page 11 EVIDENCE: Information on two residents care plans was adequate to ensure that the resident’s basic needs could be met, however some details about the residents recent needs had not been completed and this led to staff confusion about whether the service users should be receiving extra support. There was very limited information about how one service user spent their days. Staff said and the care plans checked provided evidence, that some care plans had not been regularly reviewed by the staff. There was evidence that residents and their relatives were not always involved in drawing up their care plans as there was no record of the their attendance. One resident needed to have her needs reassessed and a more detailed care plan drawn up from this to ensure staff knew how to support the resident effectively. Residents generally said that they were happy in the home and said they liked the staff. Some residents said they enjoyed attending meetings with staff to discuss holidays and activities. The residents meeting minutes did not cover many aspects of how the home was run and residents and staff confirmed they were not formally consulted on how the service should be run or developed. J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 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 standard(s) 11, 12, 13, 14 and 17. Overall, the opportunities for some service users to participate in and to develop independent living skills are limited. Some residents are able to attend and take part in appropriate activities in the local community. Daily activities and leisure opportunities had been limited due to staffing difficulties. Residents were able to maintain contact with family and friends. The mealtimes were disorganised and limited the service users opportunities to develop appropriate skills in serving and eating their meals. Residents said the meals served at the home were nice, a good range of food was in stock. Choice of food was restricted as staff did not promote menu information. J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 Page 13 EVIDENCE: The staff told the inspector that they very rarely went shopping for food or prepared meals with residents, as all this was prepared by the kitchen staff. Residents said they did not do their laundry or clean their rooms as this was all done by ancillary staff. This greatly limited the service users opportunities to develop independent living skills. Some activities were occurring during this inspection. Some residents were taking a trip to the local shops and then out to the park. Staff said this was not a planned activity and that some staff would not take service users out even if their were enough staff on duty, as they lacked direction from the acting manager and believed that some staff were lazy. Staff said they tried to organise and include the residents in activities that they organised but this was left down to each individual. Activity co-ordinators were employed but some staff said due to the staff shortages these staff had, had to work on the shifts. Residents told the inspectors that they enjoyed taking part in activities but over the recent months staff shortages had meant some of their activities and outings had been cancelled. One relative said that their daughter had very few opportunities to attend external activities and that there were very few activities organised for her in the home. Residents, a relative and the staff said that visitors were welcome at any time. Residents said that the food served in the home was nice, but they were unaware of what was available for lunch and dinner as their were no menu information. This limited the residents ability to make choices. The inspectors ate lunch with the residents. The meal time was not well planned and was served in a disorganised manner, without tables set and without condiments etc. Some service users wore plastic disposable aprons, which did not protect their dignity and other residents wandered around whilst eating their lunch. The staff did not prompt service users to support them appropriately as a result the experience was not relaxed or pleasant. Although the food was tasty. Staff said fresh fruit was not always available the kitchen staff said it was. None was seen to be offered during the inspection. Residents said that they enjoyed their lunch. J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 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 standard(s) 18 and 20 Staffing levels and gender balance at the home have at times been inadequate to enable service users to receive personal care from staff of the same gender at all times, as they would prefer. One service users care plan lacked sufficient detail to inform staff of what levels of staff support they should be receiving. This led to confusion for both the resident and the staff supporting them. None of the residents in the home administer their own medication. The current medication practices posed a possible risk to the residents’ as medication administered was not always signed for, even though a checking system is in place. EVIDENCE: Staff told the inspector that male staff had had to support female service users with personal care tasks as a result of staffing levels and inadequate gender balance on each shift over recent months. They said they felt this was inappropriate for some of the female service users. The care plans checked did not all identify whether male or female staff should support the individual resident with intimate personal care. This information must be added to ensure the service users choices and dignity are respected. J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 Page 15 The staff said and checks of the care plans and staff roster showed that although service users needs had changed regarding levels of staff support this had not been recorded in care plans and some staff had not been informed of the changes. This lead to confusion for staff and residents and resulted in a level of care below an acceptable standard. Medication was checked, overall the system was managed adequately. Staff said no service users self-medicated and risk assessments identifying why this was were in place on the files checked. Some drug sheets showed that some medication that appeared to have been administered had not been signed for. The systems in place to monitor this had not identified these anomalies, leaving residents at an avoidable risk. J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 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 standard(s) 22 and 23 A complaints procedure was in place in the home. The complaints procedure in the home was not being accessed appropriately, by staff relatives or residents. Staff reported they did not feel their concerns and complaints were always listened to and this led them to making complaints to the CSCI. Staff had completed training and had an understanding of the procedures to be followed should they suspect any abuse at the home. EVIDENCE: The residents said the staff listened to them. However, when the inspector spoke to the residents they stated activities and outings had been cancelled but no one had supported them to make a comment or complaint about this to the acting manager. One relative said he did not feel that adequate activities were available for his daughter, but had not made a complaint about this issue. An adult protection issue had not been reported to the local CSCI office in March 2005. This could have placed the residents and staff at risk. Two complaints had been reported to the CSCI in early April 2005, regarding staff shortages. The complainants said they did not feel that their views were listened to or acted upon by the acting manager and therefore they had not made a complaint to the home. Both of the complaints were partially upheld.
J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 Page 17 Requirements were made by the CSCI and action taken to address the complaints. To which the owner responded. Residents said if they had any concerns that they would speak to their keyworkers or other staff. However, none of the residents could remember making a formal complaint. Residents confirmed they had recently not been able to attend some activities or go on some outings as the home had been short staffed. No formal complaints had been made about this. One relative stated he felt the activities available to his daughter were inadequate to meet her needs. This had not been raised at a formal level as he did not wish to cause any conflict. The CSCI had been notified by an anonymous complainant, of an adult protection issue, concerning two residents at the home in March 2005. An adult protection strategy meeting was called as a result of the complaint and an appropriate action plan to protect the residents and staff was put in place by local care managers and the owner of the home. Staff had received information on adult abuse and the staff said they had been trained in adult protection procedures and managing challenging behaviour. Training records confirmed this. J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 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 standard(s) 24, 25, 28 and 30. The grounds in which the home was set had been fenced off and this improved security. The environment within the home had improved in some areas since the last inspection, however, the home was in need of a lot of redecoration and refurbishment in communal areas and residents bedrooms. Most of the communal areas appeared bare and institutional and there was a lot of old, stained and dirty furniture in these areas. Most of the service users bedrooms required redecoration, most were not personalised and many did not contain adequate fittings or furnishings. EVIDENCE: Some areas of the home including resident’s bedrooms, corridors and kitchen areas had been redecorated since the last inspection. Some new carpets and floor coverings had been laid. These areas of the home appeared clean and homely. J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 Page 19 The home has been in need of general refurbishment for the last year. Many areas appeared bare and institutional. Many carpets were faded and stained and some areas of the home looked bare and institutional. This created a neglected, unwelcoming and uncared for environment. The majority of the residents bedrooms were not decorated or furnished to an adequate standard. Bedding was worn and pillows were lumpy and smelly. Soiled bedding was found on some service users beds, which had been made ready for the service users to sleep on. Residents are dependent on staff and this level of poor care is unacceptable. The home was warm in all areas. The hot water temperature in one bathroom measured a safe temperature of 43 degrees centigrade. J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 35 and 36 There was confusion about who was in overall charge of the home when the acting manager was off duty. Staff morale was low and communication was poor. The staff lacked direction and leadership. The staff team was not working effectively in order to support the residents. None of the senior staff felt empowered to make decisions and therefore the staff team felt frustrated and lacked direction in their daily tasks. The staff reported and training records confirmed that most staff had completed training in managing challenging behaviour and the protection of vulnerable adults, in order to protect the residents. Staff lacked appropriate supervision, this resulted in residents not receiving the appropriate support they required in a consistent manner. J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 Page 21 EVIDENCE: Support staff were unaware of who was in charge of the home in the absence of the acting manager, this was an example of poor leadership and caused anxiety to staff who were also unsure of what the staffing levels in each unit should be. Several members of senior staff voiced concerns about the acting managers leadership skills and said communication in the staff team was poor. Several senior staff team told the inspectors they did not know that they had been in overall charge of the service in the absence of the acting manager. Therefore, staff had not been deployed effectively in the units. Staff therefore believed the home had been operating below the agreed minimum levels. The inspectors checked the staff rosters over the previous six weeks and found that overall, the home had not been operating under the required minimums, but the nursing units had not been adequately staffed on two occasions. Staff were unsure about which residents should be receiving extra staff support as information about this issue had not been passed down to them or put in care plans. Therefore there were occasions when the residents were waiting for staff to turn up, when they had not been rostered to work as the residents support hours had been reduced. The acting manager was struggling to manage the service due to lack of experience. This resulted in poor staff morale, high staff turnover and ultimately a very inadequate service. Senior staff said they were not empowered to make decisions and the inspectors judged that there was no leadership or ownership within each of the units. Staff said they did not have regular meetings within the units and there was therefore no real team-work. Staff said that they had undertaken relevant training to assist them in caring for the specific client group at Shirebrook Fields, this included managing challenging behaviour and the protection of vulnerable adults. Staff said that the training opportunities had increased in frequency over the past year and resulted in them feeling more confident in dealing with these issues. Training records supported this. Staff had not been individually supervised for some time, they felt there was no accountability for their performance. This frustrated the staff and resulted in residents not receiving adequate support and consistent approaches from staff.
J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38 and 39. The current management arrangements are ineffective. The management approach at the home is not appropriate. It did not create an open, positive or inclusive atmosphere to meet the residents needs or to appropriately support the staff team. The residents views do not underpin the self monitoring, review and development by the home in any meaningful way. EVIDENCE: The care given to residents meets basic primary needs, but does not meet the full range of social, emotional, cultural and spiritual needs, This resulted in residents not achieving their full potential or feeling that they are fully participating in the community. The senior staff are not clearly advised about their roles and responsibilities as at present there is a lack of unit management within each of the houses and therefore no accountability as the senior staff do not feel empowered to make
J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 Page 23 decisions within the units they work. The service offered does not encourage or promote choice and opportunities to develop skills and knowledge. The acting manager does not have an appropriate management qualification and lack of management knowledge is resulting in poor communication within the staff team, low staff morale, lack of accountability from staff who need direction and supervision in order to effectively support the residents. The management approach in the home is not supporting residents and staff effectively as issues highlighted throughout this report demonstrate. The residents have started to attend meetings with the staff and this is a positive way to begin seeking the residents views of the home, however a lot of work needs to be done to introduce quality assurance systems within the home which enable the service users views to be included in how the home is run and the future development of the service. J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 1 x x x Standard No 22 23
ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 2 2 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 1 2 x x 1 x 2 Standard No 11 12 13 14 15 16 17 1 2 2 2 x x 2 Standard No 31 32 33 34 35 36 Score 1 x 1 x 3 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 x 2 x Standard No 37 38 39 40 41 42 43 Score 1 1 1 x x x x J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 Page 25 Yes 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 YA1 Regulation 6 Requirement The service users guide must include all of the information required by the regulations. (Requirement first made on 16/6/04) The service user identified must have their needs reassessed. (Requirement first made on 13/1/05. The service users plan must contain all of the information required by the regulations. (Requirement first made on 31.3.05. ) The service user plans must be reviewed on a six monthly basis. Service users must be offered opportunities to develop independent living skills. Arrangements must be made to ensure service users can take part in planned activities Mealtimes must be planned and organised appropriately. A choice of menu must be made available to service users. Appropriate numbers of male/female staff must be available to support service users with personal care tasks to Timescale for action 31.10.05 2. YA2 12 31.8.05 3. YA6 3,15 30.8.05 4. 5. 6. 7. 8. YA11 YA12 YA14, YA17 YA17 YA18 12 12 12 12 12, 18 30.9.05 30.9.05 30.6.05 30.6.05 30.6.05 J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 Page 26 meet their individual needs. 9. YA20 13 Arrangements must be improved for the safe recording, safekeeping and safe administration of medication received in to the homeRequirement first made on 13/1/05). A review of the complaints process must be made to ensure service users, staff and relative feel able to access the procedure. All adult protection issues must be notified to the local CSCI office within 24 hours of the incident. The premises must be kept well maintained. Therefore carpets, beds, bedding, décor, furniture, fixtures and fittings must be kept clean and in good condition/well maintained (Requirement first made on 16/6/04). The person in charge of the home on each shift must be aware of their responsibilities in relation to ensuring that adequate numbers of staff are deployed in the units at all times. All appropriate staff must complete the LDAF induction and foundation training (Requirement first made on 16/6/04). Service users must be supported by an effective staff team. Team building opportunitires must be offered within the teams. The staff must be appropriately supervised to carry out their duties (Requirement first made on 16/6/04). A suitably qualified and experienced manager must be appointed. An application to register the manager with the 22.4.05 10. YA22 12, 21 30.9.05 11. YA23 37 22.4.05 12. YA24, YA25 YA28,YA30 23 31.7.05 13. YA31 21 22.4.05 14. YA32 18 30.9.05 15. YA33 12 30.9.05 16. YA36 18 30.9.05 17. YA37, YA39 9,10 31.5.05 & 30.9.05 J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 Page 27 18. YA39 24 local CSCI must be submitted to the local CSCI office (Requirement first made on 13/1/05). An effective quality assurance and quality audit systems must be developed and maintained. They must be based on seeking the views of service users and relatives (Requirement first made on 16/6/04). 30.12.05 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 YA1 YA32,YA35 YA27,YA26 ,YA24 Good Practice Recommendations The statement of purpose and service users guide should be made available in accessible formats to meet the service users needs. A training and development programme should be developed for all staff, which meets the sector skills council workforce training targets. A programme of planned maintenance and renewal for the fabric and decoration of the premises must be kept. J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 Page 28 Commission for Social Care Inspection 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
© 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 J55 S21807 Shirebrook Fields V220892 22.04.05 UI Stage 4.doc Version 1.20 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
