Inspection on 01/05/08 for Shirebrook Manor Nursing Home

This inspection was carried out on 1st May 2008.

CSCI found this care home to be providing an Adequate service.

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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shirebrook Manor Nursing Home 02/05/07

Shirebrook Manor Nursing Home 23/05/06

Shirebrook Manor Nursing Home 24/02/06

Shirebrook Manor Nursing Home 31/08/05

Shirebrook Manor Nursing Home 31/01/05

Shirebrook Manor Nursing Home 06/10/04

Similar services:

Hillside

Applegarth

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Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Shirebrook Manor Nursing Home Central Drive Shirebrook Nottinghamshire NG20 8BA Lead Inspector Nancy Bradley Unannounced Inspection 1st May 2008 09:00 Shirebrook Manor Nursing Home DS0000002074.V363767.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 Manor Nursing Home DS0000002074.V363767.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 Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shirebrook Manor Nursing Home Address Central Drive Shirebrook Nottinghamshire NG20 8BA 01623 744414 01623 748882 shirebrookmanor@shirebrookcaregroup.co.uk 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 Nursing Home Limited Manager post vacant Care Home 33 Category(ies) of Learning disability (33) registration, with number of places Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Shirebrook Manor Nursing Home is registered to provide personal care with nursing, to male and female service users who fall within the following categories: Learning Disability (LD) 33 The maximum number of persons to be accommodated at Shirebrook Manor Nursing Home at any one time is 33 2nd May 2007 2. Date of last inspection Brief Description of the Service: The Care home is situated in the village of Shirebrook, which lies on the Derbyshire and Mansfield boundaries. The home is purpose built for the provision of nursing care to a maximum of 33 service users with a learning disability. The home comprises of two floors with each floor being divided into smaller units, one of which provides care to service users with a challenging nature. The home also provides a small day care facility, for the residing service users. The current scale of charges is a basic £900.00 to £1783.79 per week. The information on additional charges was not available. Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced key inspection and took place over a total of six hours. We spoke with the manager, care staff and people living at the home. The inspection activity during this site visit was to assess the service against the key National Minimum Standards and these are identified through the report. We looked at all the information that we received or asked for, since last key inspection. This included the following: The annual quality assurance assessment (AQAA) that was sent to us by the home. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the home. Additionally, time was spent in preparation for the visit, looking at the service history and the previous inspection report. Records were examined relating to the people living there and the general running of the home. We sent out “Have Your Say” questionnaires and we received four completed questionnaires from people living there who confirmed they were very happy at the home and were looked after by the staff and would not wish to live anywhere else. We received five completed questionnaires from relatives and twelve from care staff. All were satisfied about the care, however all stated they had concerns about the condition of the home and that the refurbishment had not been started. What the service does well: The home provides care for younger adults with very challenging behaviour some of which are now very frail having been at the home for a number of years. All of the people living at the home have a care plan and the majority of the people stated they are aware and have signed them to show they agree. The atmosphere within the home generally was warm and friendly, good relationships were observed between the care staff and people living there. Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 6 People living there have stated they like and enjoy living at Shirebrook Manor The home provides good levels of staffing The home offers an activities programme, which includes trips out into the community as well as activities within the home. Several of the people living at the home now have their own pets to care for. What has improved since the last inspection? 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 Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 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 Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are now in place to ensure that people’s needs are fully assessed prior to admission. People’s care could be further enhanced by regular reviews of their care needs assessment. EVIDENCE: The records of three people living at the home were checked. The majority of the people 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 home also undertakes its own individual comprehensive needs assessment and which is in accordance with Shirebrook Care Ltd assessment process and the National Minimum Standard 2.3. The assessment then forms part of the care plan compiled by the home. The majority of the care needs assessments examined were of people who had been living at the home for a long time and the initial assessment provided very little information. The home is developing a system for recording significant events in the peoples lives, however this is proving difficult, as many of them do not have any significant family or friends. There was little evidence on record to show that the care needs assessments were being reviewed by the referring agency. Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 10 There have been no new admissions since the previous site visit. Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 11 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. Although some work has been undertaken in this area continuing inconsistencies in the care planning system and recording may compromise the service people living at the home receive. EVIDENCE: During the visit care plans of four people who live at the home were seen. The nurse/key worker for each person at the home had compiled the care plan and evidence was seen of care plans being reviewed on a regular basis. People living at the home who were case tracked had a care plan, which was in accordance with their assessed need and formulated within a risk assessment. All care plans were very detailed people’s individual lifestyle preferences and choices; the interventions prescribed by outside healthcare professionals were appropriate. Daily records are also maintained on each person who lives at the home. As discussed with the manager and the responsible individual care plans were at different levels, there were still some inconsistencies in the planning. The responsible individual stated they had noted this in their audit of Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 12 care plans and were addressing it with the staff concerned. Inconsistencies were around information on peoples’ life history and details in how the person would receive the care. There was evidence to show that people at the home had been consulted about their care plan. Although the people at the home have server learning disabilities and not always able to communicate their wishes, several of the key workers had taken time and effort to go through the care plan and they had signed to show they understood and agreed. Discussions with one person at the home and from the questionnaires received confirmed they had been made aware of the care plan and knew what was in it. The AQAA indicates the home is looking to introduce a more person centred planning system. During the tour of the home care staff were observed encouraging service users to make decisions, which affect their daily lives. People living at the home knew who their key worker was and told us how they help them on a daily basis All service users have access to the Derbyshire Advocacy Service should they require and the home is setting up service user meetings with the Advocacy Service. Risk assessments were in place covering such issues as, people’s health and safety, physical health, nutrition, mobility, tissue viability, and risks associated with social activities. Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 13 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, which enable people to maintain and develop appropriate relationships, and to participate in activities both in the home and outside in the wider community in accordance with their preferences and wishes. EVIDENCE: The care records of four people living at the home provided details of care planning and risk assessments of their social, recreational, educational and occupational activities both within the home and outside in the community. On the day of the visit people living in the home were involved in reflexology, aromatherapy and bowling. The daily activities are displayed on the homes’ information board in an easy read format. People living at the home stated they like living there and liked the activities on offer. Relatives are also encouraged to join in the activities. Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 14 The daily routines are flexible with people being able to make their own decisions about how they spend the day. The relationships observed between care staff and people living at the home were open and friendly and good humoured. The staff encouraged the people living at the home to take pride in their appearance and their individual dress sense is respected. The daily routines are flexible with every one being able to make their own decisions about how they spend the day. Information on peoples’ records indicated that contact with family and friends were appropriate. Any restrictions on contact are recorded in care plans. People at the home can speak with family and friends by telephone if they wish. The AQQA shows the people from Shirebrook Manor are involved in developing a quarterly newsletter called the Shirebrook Mews. The daily menus indicate that the people who live at the home are provided with a healthy well-balanced and nutritious diet. People at the home made positive comments about the meals and said their likes and dislikes are taken in to account. During lunchtime every one was given a choice of menu. We had lunch with everyone at the home. Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 15 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, 20 and 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive personal and health care support in a way, which promotes their independence and is in accordance with their preferences and beliefs. EVIDENCE: From records seen and from discussions with staff, peoples’ health and personal needs are being met People living at the home are generally healthy and records showed that staff promptly contacted the appropriate medical services when necessary People living at the home are registered and attended services within the community including doctor optician, podiatrist, dentist, and audiologist. The people at the home said they have a choice of a showering or bathing daily. A record is kept of people who are at risk of developing pressure sores and several of the people like to have their weight recorded. People at the home see this as part of maintaining a healthy life style. Most of the people at the home have some contact with learning difficulties service at Ashgreen. Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 16 The home maintains records of all hospital and doctor visits. The home operates and monitors medication administered no one is able to self medicate unsupervised. All staff have received training on medication procedures. The arrangements for receipt, storage, administration and disposal of medication were also examined and found to satisfactory. The home has reviewed its policy for homely remedies and all non-prescribed medication is fully recorded ensuring people health is fully protected. The home has their medication supplied from the local pharmacy who carries out regular inspections. The deputy manager is also carrying out monthly checks on all medication received and administered. At present the home is caring for some very frail people and as part of meeting their care need the home needs to have their end of life plan fully completed. Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 17 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. Arrangements are in place to safeguard peoples’ welfare and ensure that their concerns are listened to and acted upon. However current practice leaves people living at the home vulnerable. EVIDENCE: People living at the home are made aware of the home’s complaints procedure through the service user guide and via their key worker. A copy is displayed on the homes notice board in an easy to read format. Any concerns and complaints made by people living at the home or their relatives are investigated within the agreed time scales. The manager maintains a record of all complaints made by service users, details of the investigation action and outcome. The complaints procedure contains the current contact details of the Commission for Social Care Inspection and informs the complainants that they are able to contact the Commission at any stage of the complaints process if they wish to do so. We have not received any formal complaints from people or their relatives about their care since the site visit. The home has received one compliant about its service, this was dealt with in the correct manner. Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 18 Discussions with the manager and records seen indicate that there have been two reported incidents of allegations under the safeguarding of adults procedure since the last site visit. These have now been concluded. The home has a safeguarding adult protection policy and procedures however this does not make reference to local procedures. This was raised as an issue the previous site visit. Staff training records confirmed they had received training on safeguarding of adults. Information provided in the AQAA showed there have been occasions when the staff have used physical intervention strategies, on people living at the home. We viewed these records and found the details were insufficient; for example clarification of “floor restraint” is required. The information recorded needs to be more detailed so the people living in the home are fully protected. The shortfall in recording should have been noted by the management of Shirebrook Care People living at the home have a poor level of communication so are not able to express their concerns about physical interventions, or about not being safe. Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 19 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 poor. This judgement has been made using available evidence including a visit to this service. The environment is poor for people living at the home, effecting their daily lives and independence. EVIDENCE: We carried out a full tour of the home as a result of previous requirements and were, accompanied by the manager. All communal areas were viewed together with staff facilities. Peoples’ bedrooms were viewed with their agreement and all rooms had been decorated and furnished to their personal choice and were being personalised. During the tour of the home we noted that there were no chairs in peoples’ bedrooms, one headboard was split and pillows were very flat. Relatives had also raised these area is in their returned surveys. The issues relating to the environment and the general condition of the building have been identified in the three previous reports. The refurbishment of the building is urgently required. At a resent meeting with representatives from Shirebrook Care Ltd, and an assurance were given that this was imminent Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 20 No ongoing repairs have been made to the home and the condition has deteriorated since our last site visit. People on the Phoenix unit live continue to live in an environment of control and containment with little comfort in their surroundings. Plastic seating, some curtains to windows, tables and chairs secured to the floor. The generally the home was free of any unpleasant odours or smells with the exception of the Phoenix unit. On entering the unit there was a strong odour. The home has satisfactory hygiene procedures in place. Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 21 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 and selection procedures in place to ensure that the appropriate staff are employed to care for vulnerable people. EVIDENCE: The home has a high percentage of staff who hold a NVQ level 2/3 or the equivalent, with several staff being approved trainers for safeguarding adult and physical intervention. The staff working on the “ Phoenix unit” are registered nurses in mental health or learning disability and the care staff work along side them. As discussed with the manager and the responsible individual, newly appointed staff need to reflect the changing needs of the home, and that of the people living there. The staff numbers and skills mix of the teams needs to be integrated to benefit the effective operation of the home. The home has a robust recruitment procedure in place, which ensures that their staff are suitable to work with vulnerable people. Several staff personnel records were examined which confirmed that thorough employment checks were carried out. Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 22 All new staff are required to provide two references, a full employment history, have a clear Criminal Records Bureau clearance and complete a 3 months probationary period. The records contained all required information has detailed in Schedule 2 of the National Minimum Standard, Care Homes for Adults 2001. The staff personnel records were well presented and organised. All staff receive induction training and commence comprehensive foundation training with 3 months of appointment. From discussions with the manager and from examination of records the home is providing good training and development opportunities. Details of staff training together with training planned were provided by way of the AQAA. The training programme covered Mental Capacity Act, fire training and person centred planning. Although staff supervision is taking place and records were seen confirming this, the manager did state that several staff are not receiving regular supervision as required under National Minimum Standard 36.4. Staff appraisals have been arranged. This was an issue at the pervious visit and has been raised by staff in questionnaires received by us. Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 23 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, 40 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 is generally well managed, with staff seeking the views from the people who live there. EVIDENCE: The manager has a number of years experience in the care sector, and is working towards a recognised managers award. Examination of her personnel records confirmed she had a contract and relevant job description detailing her role and responsibilities. As confirmed by the AQAA the manager has not submitted her application for registered manger status to us. This must be done as soon as possible as the manager has been in post since July 2007. Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 24 The manager stated that a process for monitoring care and services provided has been established and this is in line with the policy operated within Shirebrook Care Ltd. The manager stated there is no other formal system for reviewing the quality of care provided. However she is looking to establish a group discussion with people living at the home about the refurbishment. The last meeting was August 2007. As discussed with the manager quality assurance procedures could be improved with further consultation being undertaken with stakeholders and family and friends. As indicated in the AQAA several of the home’s policies and procedures require updating. Although the AQAA indicates the provider is undertaking regulation 26 visits, the home did not have up to date copies of these visits. The AQAA dataset indicated that all the necessary maintenance checks had been undertaken. Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 2 X 2 2 X 3 X Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 26 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 15 Requirement All care needs assessment must reviewed regularly to ensure people’s needs are fully assessed and any changes in there is care are recorded. The homes policy on Safeguarding Adults must make reference to local procedures. This is a previous requirement. The home must be suitable for the needs of the people who live there and be maintained both internally and externally. This is a previous requirement. Shirebrook Care Ltd must proceed with the planned refurbishment and extension to the home and dates must be provided as to when this will commence. This is a previous requirement All staff must have regularly supervision in line with the National Minimum Standard 6.4. This is a previous requirement The manager must submit her application to register with us as soon as possible. DS0000002074.V363767.R01.S.doc Timescale for action 30/06/08 2. YA23 15 30/06/08 3. YA24 23 30/06/08 4. YA34 23 30/06/08 5. YA36 18 30/06/08 6. YA37 24 30/06/08 Shirebrook Manor Nursing Home Version 5.2 Page 27 7.. YA39 39 As part of assessing the quality of care provided by the home consultation with stakeholders family and friend of people who live there must be undertaken. The registered provider must undertake regular visit to the home and maintain a written record of these visits for people living at the home. The home must have up to date polices and procedures which must be available to people, living at the home. 30/06/08 8. YA39 26 30/06/08 9. YA40 24 30/06/08 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. Refer to Standard YA7 YA21 Good Practice Recommendations The home should consider Personnel Centred Planning as ways of developing peoples’ involvement in their care. The home should complete all peoples end of life plans. Shirebrook Manor Nursing Home DS0000002074.V363767.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Text phone: 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. 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