Inspection on 01/12/07 for Shirebrook House

This inspection was carried out on 1st December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shirebrook House 20/11/09

Shirebrook House 17/08/09

Shirebrook House 02/12/08

Shirebrook House 18/06/08

Shirebrook House 02/03/07

Similar services:

Hillside

Applegarth

122 Scorer Street

St Marys Nursing Home

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Shirebrook House Shirebrook House 19 Station Road Borrowash Derbyshire DE72 3LG Lead Inspector Nancy Bradley Unannounced Inspection 3rd December 2007 09:30 Shirebrook House DS0000067849.V352326.R01.S.doc Version 5.2 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 House DS0000067849.V352326.R01.S.doc Version 5.2 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 House DS0000067849.V352326.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shirebrook House Address Shirebrook House 19 Station Road Borrowash Derbyshire DE72 3LG 01332 725734 0114 2691133 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 Manager post vacant Care Home 10 Category(ies) of Learning disability (10), Physical disability (10), registration, with number Sensory impairment (10) of places Shirebrook House DS0000067849.V352326.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are: Learning disability - Code LD Physical disability - Code PD Sensory Impairment - Code SI The maximum number of service users who can be accommodated is 10 2nd March 2007 2. Date of last inspection Brief Description of the Service: The Care home is situated in the village of Borrowash, which lies on the Derbyshire and Nottingham boarder and owned by the Shirebrook Care Limited, which is a privately owned company. The home provides residential care for ten adults, whose primary needs include sensory impairment, learning and physical disabilities. The building is a detached house situated on a housing estate in Borrowash close to local amenities. The premises were previously registered as a care home for older people but voluntarily closed in January 2004. The property was sold to Shirebrook Care Limited in 2005, and the Company has carried out significant improvements to the building. The accommodation is spacious and has been adapted to meet the needs of the people who will live there. Facilities for service users are located on the ground and first floor; the staff and sleeping in room is located on the second floor. The home has ten single bedrooms with en-suite facilities; all rooms except for two rooms have shower facilities. The dining and lounge areas, kitchen, laundry and conservatory are on the ground floor. A ‘walk in’ shower room and a bathroom with a bath and tracking hoist are located on the ground floor; the three bedrooms on the first floor have en-suite shower facilities. Information on fees was not available Shirebrook House DS0000067849.V352326.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection and took place over a total of six hours. During the site visit the inspector made a tour of the home and spoke with several residents and staff. The inspection activity during this site visit was to assess the service against the key National Minimum Standards and these are identified through the report. At the time of the visit service users where living at the home; the home currently has vacancies for four service users. Additionally, time was spent in preparation for the visit, looking at the service history, and the previous inspection report. The Annual Quality Assurance Assessment questionnaire was not available at this inspection, as the questionnaire was not sent out in time for the inspection. Records were examined relating to the service users and the general running of the home. The Commission for Social Care Inspection send out the six “Have Your Say” questionnaires. The Commission for Social Care Inspection received two completed questionnaires, from services users who confirmed they were happy at the home and were looked after by the staff. The Homes Statement of Purpose, Service user Guide and inspection report from the Commission for Social Care Inspection were displayed in the main entrance. What the service does well: What has improved since the last inspection? The home now employs an activities co-ordinator to provide both educational and occupational activities. Shirebrook House DS0000067849.V352326.R01.S.doc Version 5.2 Page 6 The parents of service users have started their own Advocacy Group The home is having a lift installed making the upstairs accessible to all service users. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Shirebrook House DS0000067849.V352326.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 House DS0000067849.V352326.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that service users needs are fully assessed and met prior to admission. However the home is not always following the agreed procedures. EVIDENCE: The records of two service users were examined. The majority of the service users who are admitted to the home have their needs assessed through the care management system, which highlights their additional needs, and the need for additional staffing hours. The assessments then form part of the service user plan compiled by the home. The home also undertakes their own individual comprehensive needs assessments. This is in accordance with the Shirebrook Care assessment procedure to provide a person-centred record of service users’ individual needs. The assessments also record sufficient events in the service user’s life. However the homes initial assessment on a new service user was not available at the time of the visit. There was evidence on record to show that care management were reviewing the care needs assessment on a regular basis. Shirebrook House DS0000067849.V352326.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Inconsistencies in the care planning system and recording may compromise service delivery and leave service users vulnerable EVIDENCE: During the visit care plans of two service users were examined. The care staff for each service user have compiled the individual care plans and evidence was seen of care plans being evaluated monthly. There was no evidence of care plans being formally reviewed on a six monthly basis. However the care plan for one service user cased tracked was incomplete. The home was using the previous homes care plan and risk assessments. Language in the care plan and risk assessments was inappropriate and not relevant to the current placement. The care plans used are the Shirebrook group Care corporate documentation, which are based on a nursing model rather than a social care model. The home has started to compile a life history for each service user, and is looking to follow a Personal Centre Planning approach. Shirebrook House DS0000067849.V352326.R01.S.doc Version 5.2 Page 10 The service user’s involvement in drawing up the plan should be through family, friends and/or advocates, and/or other relevant agencies. One service user had signed their care plan, however there was little evidence of the service user’s part in the decision making process, although care staff were observed encouraging service users to make decisions which affect their daily lives. All paperwork should be signed and dated. Risk assessments were in place, these need to show actions staff should take after the risk has been identified and assessed. Also additional areas of risk need to be assessed and included in service users’ records, for example tissue viability, trips and activities. These need to be updated and reviewed in line with care plans. Shirebrook House DS0000067849.V352326.R01.S.doc Version 5.2 Page 11 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): Standards 12, 13, 15, 16, and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were arrangements in place to enable service users to maintain and develop appropriate relationships. The home provides a well-balanced and varied menu. EVIDENCE: During the visit the inspector observed service users and care staff engaged in activities and discussed with the staff the arrangements for these. The care records of all service users provided needs assessment and care planning information regarding their social, recreational, educational and occupational activities both within the home and outside in the community. Following the previous inspection report the home has now employed an activities co-ordinator, who has arranged a full activities programme for the home. This provides opportunities for service users to attend the local adult education class. Shirebrook House DS0000067849.V352326.R01.S.doc Version 5.2 Page 12 The service users choices and preferences were identified, however there is the need for properly recorded risk assessment to be in place for each service user in relation to the activities they are engaged in. Information on service users’ records indicated that contact with family and friends were appropriate and that they play an important part in their daily lives, the home maintains good contact with them. Currently the home does not have any restrictions on contact The staff and service users described the daily routine as flexible and that they were able to make their own decisions about how they spend the day. The relationships observed between care staff and service users were open and good-humoured. The service users are encouraged to take pride in their appearance and their preferred style of dress is respected and encouraged. From examination of the menus the home is providing a healthy well-balanced and nutritious diet with some service users on special diets. The manager has compiled a user–friendly menu for service users using pictures. Services users have a choice at meals times. Service users’ weekly weights are recorded. At present the home is operating without a cook and the care staff are required to prepare and cook the meals. The manager confirmed that all staff have received food hygiene training, although certificates were not displayed to confirm this. Currently the home is not fully occupied, when this happens there will be a need for alternative arrangements to be put in place. Care staff need to be predominately with service users rather than being occupied in the kitchen. There is a risk of cross contamination/infection with care staff attempting to undertake both roles. Shirebrook House DS0000067849.V352326.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in ways, which enables them to be independent and have control over their lives. EVIDENCE: The majority of service users were not able to express themselves verbally and to directly contribute to the inspection. During a tour of the home the inspector observed that service users looked relaxed and contented. Direct observation indicated that the majority of service users required some assistance with personal support. Several of the service users have a high level of need and support. During the visit it was clear that the service users’ privacy and dignity are respected, and where service users needed supervision during personal care this is recorded in their care plan. However there is an issue of service users privacy when in their bedrooms and in some communal areas. This is raised at the previous inspection and is detailed later on in the report under the environmental section. Discussions with staff indicate that they have satisfactory insight into the needs of individual residents and are committed to supporting and assisting them. It is important that there are up to date and detailed records on how Shirebrook House DS0000067849.V352326.R01.S.doc Version 5.2 Page 14 service users’ needs are addressed, and to safeguard service users by ensuring that their total needs are identified and responded to. Records examined from discussions with staff indicate service users’ health and personal needs were being met Service users were generally healthy and records show that staff promptly contacted the appropriate medical services when necessary. However service users are not routinely accessing annual health checks. Discussion with the manager as to how this could be developed concluded that each service user could have his or her own health plan. All service users attended services within the community including optician, podiatry, dentist, audiologist, and speech and language therapist. The home operates and monitors service users’ medication. None of the service users are able to administer their own medication. All staff have received training on medication procedures. The arrangements for receipt, storage, administration and disposal of medication were also examined and found to be satisfactory. Medication administration is recorded on Medication Administration Records (MAR sheets). Shirebrook House DS0000067849.V352326.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were suitable systems and arrangements in place to promote the safety of service users and staff. However the lack of training on safeguarding leave service users and staff vulnerable and at risk. EVIDENCE: Service users are made aware of the home’s complaints procedure through the service user guide and via their key worker, a copy is also displayed in the home. The Manager has developed a user-friendly complaint form for service users. Any concerns and complaints made by service users are investigated within the agreed time scales. The Registered Manager maintains a record of all complaints made by service users, details of the investigation action and outcome. The procedure contains the contact details of the Commission for Social Care Inspection office in Sheffield not the local office for the area. This was raised with the manger at the time of the visit. The policy informs the complainants that they are able to contact the Commission at any stage of the complaints process if they wish to do so. The home’s policy on Safeguarding Adults was examined. This is a corporate policy and has been updated to cover Safeguarding of Adults. The policy needs to be updated to reflect the change in emphasise from abuse to safeguarding. Staff training records examined confirmed that four staff out of twelve had undertaken training on Safeguarding of Adults. Shirebrook House DS0000067849.V352326.R01.S.doc Version 5.2 Page 16 There has been no reported incident of Safeguarding of Adults since the last inspection. The manager reported that two staff had completed physical intervention training. The system for dealing with service users’ personal monies was discussed with the manager. The manager is solely responsible for service users’ monies. Service users appeared to be satisfied with this system. Shirebrook House DS0000067849.V352326.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The general standard of the home and the environment are good providing service users with an attractive and comfortable place in which to live. EVIDENCE: The Inspector carried out a full tour of the home, accompanied by the manager. All communal areas were inspected together with staff facilities. Service users’ bedrooms were inspected with their agreement and all rooms had been decorated and furnished to their personal choice and were being personalised. The family of one service user have purchased furniture for their bedroom. The home was clean, well maintained, well furnished, equipped and well lit and heated. There is a central kitchen and separate laundry and staff facilities. All of the bedrooms are single with en-suite facilities. As discussed with the manager several of the bedrooms and communal rooms look out on to the street, with the majority of the rooms having blinds fitted to the windows. However, these are pulled up and in the day and do not allow Shirebrook House DS0000067849.V352326.R01.S.doc Version 5.2 Page 18 the service users any privacy from the street. This was raised as an issue at the previous inspection. The home has a conservatory and a small garden / patio area, which could be used by the service users to sit out at various times of the year. There are no outstanding maintenance issues. The home is having a lift fitted. The home has satisfactory hygiene procedures in place. Shirebrook House DS0000067849.V352326.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,34 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has robust recruitment procedures and practices in place which ensure the safety and protect the service users. Service users are well supported by an effective staff team who are appropriately trained. EVIDENCE: The home operates a key-worker system and the staff spoken with during the visit where aware of the individual needs of the service users. Discussions with the manager and from records examined confirmed that the home has a good percentage of staff who hold a NVQ level 2/3 or are working towards attainting the qualification. The home has a recruitment and selection policy in place. Several staff records were examined and generally these were well presented. All staff have a current Criminal Records Bureau check, are required to provide two personnel references. Interview minutes were signed and copies of qualifications were available for inspection. However interview minutes were being recorded in pencil. Shirebrook House DS0000067849.V352326.R01.S.doc Version 5.2 Page 20 As part of providing a full employment history all applicants should provide the day, date month and year. As most applicants were only providing the month and year, gaps in employment cannot be fully explored. All staff are subject to a six months probationary period. Discussions with the manager and from examination of records the home is providing a variety of training and development opportunities. Details of staff training together with training planned were provided at the inspection. Training on the Mental Capacity Act 2007 needs to be included in the training. All staff have a Personal development Plan. The home has a staff supervision policy in place and is in line with the National Minimum Standard 36.4. However examination of records did not support this, with some staff stating they had not received any formal supervision at all. Staff appraisals have not been undertaken. Shirebrook House DS0000067849.V352326.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home must have quality assurance system in place, to ensure that service users have a voice, their views are listened to and the home is run in the best interest of the people who live there. EVIDENCE: Since the last inspection the Registered Manager has resigned and a new manager has just been appointed. As discussed at the visit the new manager needs to needs to submit her registered managers application to the Commission for Social Care Inspection. The manager is due to commence the Registered Managers Award in January; currently the manager has a NVQ level 3 in care. The Operations Manager is providing additional support. The Registered Provider has undertaken no formal quality assurance, but the views of the service users are sought on a one-to-one basis on a regular basis. The manager has an open door policy and is available to speak with service Shirebrook House DS0000067849.V352326.R01.S.doc Version 5.2 Page 22 users’ families at any time. The Registered Provider undertakes Regulation 26 visits and checks quality and performance matters on a monthly basis The parents of service users are quite active and have set up their own Advocacy / Support group. A sample of other maintenance documentation was examined and there was evidence of appropriate checking/maintenance of the main services at the home e.g. gas and electrical services. The new manager is updating the environmental risk assessments in particular the ones relating to the Control of Substances Hazardous to Heath Regulations (COSHH ). Shirebrook House DS0000067849.V352326.R01.S.doc Version 5.2 Page 23 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 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 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 2 3 X 2 X 2 X X 3 X Shirebrook House DS0000067849.V352326.R01.S.doc Version 5.2 Page 24 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 YA2 Regulation 14 Requirement Timescale for action 31/01/08 2. YA6 15 3. YA6 15 The home must have a current and valid care needs assessment on all services users’ before they are admitted. Comprehensive individual plans 31/01/08 of care must be developed for each service user to demonstrate that assessed and changing care needs are being reviewed and addressed. Individual plans of care must be 31/01/08 drawn up with the involvement of the service user, family or advocate where appropriate so that they fully reflect the assessed needs of the service user. This is a previous requirement All risk assessment must reflect the individual level of need and actions to be taken in respect of their health and safety. This is a previous requirement All risk assessments must be kept under review and take account of any change of circumstances. This is a previous requirement DS0000067849.V352326.R01.S.doc 4. YA9 14 31/01/08 5. YA9 14 31/01/08 Shirebrook House Version 5.2 Page 25 6. YA12 13 All activities involving service users must be subject to an appropriate risk assessment. This is a previous requirement. The home must have a clear and up to date medical history and health plan for all service users. The complaints procedure must include the current contact details of the Commission for Social Care Inspection. This is a previous requirement. All staff must complete training on the safeguarding of Adults. The home policy must be reviewed to reflect the change of emphasis from abuse to safeguarding. The Registered Person must ensure that suitable curtain are provide to the windows that are street facing. This covers both service user bedrooms and any communal rooms. This is a previous requirement. All applicants must comply with the homes policy and procedures on staff recruitment as outlined in Schedule 2 of the National Minimum Standards. This is a previous requirement. All staff must have regular supervision in line with the National Minimum Standard 36.4 All personnel records including those relating to the Registered Manager must be available for inspection. This is a previous requirement The Manager should make an application to be registered with the Commission for Social Care DS0000067849.V352326.R01.S.doc 31/01/08 7. 8. YA19 YA22 12 22 31/01/08 31/01/08 9. 10. YA23 YA23 6 18 31/01/08 31/01/08 11. YA24 16 31/01/08 12. YA34 Schedule 2. 19 31/01/08 13. 14. YA36 YA37 18 Schedule 2.9 31/01/08 31/03/08 15. YA37 9 31/03/08 Shirebrook House Version 5.2 Page 26 Inspection. 16. YA39 24 The home must establish and maintain a system for reviewing the quality of care provided to service users. 31/03/08 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 YA34 YA35 YA35 Good Practice Recommendations All applicants should provide the day date month year when providing a full employment history. The Registered Person should undertake some team development as a way of addressing staff issues. All should undertake training on the Mental Capacity Act 2007. Shirebrook House DS0000067849.V352326.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Shirebrook House DS0000067849.V352326.R01.S.doc Version 5.2 Page 28 - 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. 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