Inspection on 23/05/06 for Shirebrook Manor Nursing Home

This inspection was carried out on 23rd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shirebrook Manor Nursing Home 01/05/08

Shirebrook Manor Nursing Home 02/05/07

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

122 Scorer Street

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 09/07/2008.

CARE HOME ADULTS 18-65 Shirebrook Manor Nursing Home Central Drive Shirebrook Nottinghamshire NG20 8BA Lead Inspector Nancy Bradley Unannounced Inspection 23rd May 2006 09:30 Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Shirebrook Manor Nursing Home Address Central Drive Shirebrook Nottinghamshire NG20 8BA 01623 744414 01623 748882 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 Vacant Care Home 33 Category(ies) of Learning disability (33) registration, with number of places Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 24th February 2006 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. Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over six hours. The inspector spoke with Registered Manager, Mrs Naomi Reynolds, representatives from the company, and members of staff on duty. During the site visit the inspector made a tour of the home and spoke with several service users. A number of the service users had difficulties in expressing themselves in words and were unable to contribute directly to the inspection. The inspector did observe throughout the visit as to how service user needs were being met by the staff. Records were examined relating to the service users and the running of the home. The inspector had Lunch with the service users. No family or relatives were present during this visit. What the service does well: What has improved since the last inspection? What they could do better: The Registered Manager stated that the plans have been finalised for the building alterations. The home was originally built has an older persons home so the alterations will bring the home in line with the current service user group. The Registered Manager is current looking to change the style of care plans and the method of recording. Although the staff were clearly committed to the service users’ general welfare it was noticeable that several staff prefer to work to previous management styles of containment and control. The management is aware of this and is Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 Page 6 looking to change the ethos of the home and staffs’ understanding of their roles. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 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 Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Quality in this out come area is adequate. This judgement has been made using the available evidence including a visit to this service. Service users needs are assessed prior to admission; however the assessment process requires further strengthening to ensure that all the required information is available so that the service users’ individual needs can be fully assessed and met. EVIDENCE: The records of four service users. were checked. 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 forms part of the service user plan complied by the home. The assessments examined general did not fully detail medical history, daily needs and preferences. The majority of the assessments examined were of long-term service users. Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6 and 7 Standard 9 is not applicable to this service Quality in this out come area is adequate. This judgement has been made using the 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: The Registered Manager is looking to implement new care planning, risk assessments and individual profiles on all service users. During the visit the inspector was able to examine both systems of care planning. The new care planning system is being phased in. On examination of records inconsistencies was noted in care planning, the level of recording and evaluation of care plans. According to one-service users records there had been no change in four years. The service user involvement in drawing up the plan should be through family, friends and/or advocates, and other relevant agencies care plans should be revised at least every six months, to reflect in changes in need and the effectiveness of the care plan. Progress in the care planning systems will require further assessment. Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13 15 16 and 17 Quality in this out come area is good. This judgement has been made using the available evidence including a visit to this service. The home provides a programme of activities to stimulate and entertain the service users; this includes specialist facilities for people with severe disabilities. However records show that risk assessments are not in place, which potentially leaves service users at risk. The home offers well balance and nutritious meals. EVIDENCE: The home has introduced weekly activities for the service users, and this is lead by a team of day care workers’. The programme includes activities out in the community as well as home based. Service users have trips out to the local leisure and garden centres, and the staff have developed two specialist soft play areas within the home. During the visit service users were going out shopping in the community. The activities programme is compiled by the day care workers following discussions with service users. The service users do have the option on whether they take part the activities, and one service user spoken with helped out on a farm Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 Page 11 In discussions with the team leader, currently there are no risk assessments in place on these activities. The team leader is responsible for the formal supervision of the day care staff. Service users described the daily routine as flexible and that they were able to make their own decisions about how they send the day. Information on service users records indicated were contact with family and friends was appropriate. During the visit the inspector joined the service users for lunch. The service users are given a choice if they do not like the options on the menu. The staff were observed checking with service users has to their preferences. The home operates a three weekly menu. In discussions with the staff, variations to the menus are not being recorded. From examination of the menus the home is providing a healthy well-balanced and nutritious diet. The recent Environmental Health report did not raise any concerns. Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 18 19 and 20 Quality in this out come area is adequate. This judgement has been made using the available evidence including a visit to this service. Service users looked well cared for and interaction between staff and service users was relaxed and respectful. Information on service users’ health care plans must be accurately recorded to assist care staff in meeting individual need. EVIDENCE: Many of the service users are not able to express themselves verbally but several service users spoken with said “that the staff look after them well and that they liked it at the home.” They said that “they get the help that they need to get dressed, go out, get washed and see their doctors if they needed to.” Service users were clean and were dressed in age appropriate clothing. Those service users who were less able to express themselves verbally looked relaxed, talking or watching television. Information in one service users health care plan did not fully detail the changes, which had been made in medication following a hospital review. Information relating to visits from health care professionals was recorded, however there were variations in the style and level of recording. This was discussed with the Registered Manager as a training need. Currently there are no service users who self-administer their own medication. Medication policy and procedures will be examined in detail at the next site visit. Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 22 and23 Quality in this out come area is good. This judgement has been made using the available evidence including a visit to this service. The home has policies and procedures in place, which allows service users a voice and protects them from harm EVIDENCE: Service users were made aware of the complaints procedure through the service user guide as well as their key worker. Service users have made complaints and these were 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. There has been one adult protection issue raised in the home since the last inspection and this was referred to the appropriate agency. The home followed their policy and procedures for the safe guarding of adults. The Commission for Social Care Inspection was informed of the on going investigation. Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 24 and 30 Quality in this out come area is poor. This judgement has been made using the available evidence including a visit to this service. The homes’ improvement programme needs to be implemented to ensure the service users live in a safe, comfortable and homely environment. EVIDENCE: The issues relating to the environment and the general condition of the building, which had been identified in the two previous reports, have been addressed. On a tour of the building the inspector found the following issues: • Carpet in the down stairs corridor had risen up. • Two metal pipes sticking out from the carpet opposite the downstairs soft play area. • The laundry area requires refurbishment. . The rear stairs leading to service user bedrooms smelt of smoke. • Windows only had one restrictor fitted. • Service users wardrobes fitted with padlocks. • One service users bedroom had the operating taps removed. • Bedrooms painted in appropriate colours. • Bedrooms offering very little or no comfort to the service users. Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 Page 15 The environment in Phoenix is one of control and containment with the service user being offered very little comfort in their surroundings. Plastic seating, no curtains to some of the windows, tables secured to the floor, and hard floors. The Registered Manager has been able to re decorate several of the service user bedrooms and is actively looking to soften the environment for the service users. Some of the issues identified will be addressed with the refurbishment plan. Were this is for the safety of service users’ risk assessments and care plans must be updated to reflect practise. The home was free of any unpleasant odours or smells. The domestic staff were seen to be working very hard to maintain a clean and hygienic environment within the limitations the building allows. Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 32 33 34 and 35 Quality in this out come area is good. This judgement has been made using the 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. Generally there were sufficient staff on duty to meet the needs of the home however the staffing levels need to be kept under review. EVIDENCE: The recruitment files of six staff were looked at as part of the site visit, two of which were the most recently employed staff at the home. The records contained all required information has detailed in Schedule 2 of the National Minimum Standard, Care Homes for Adults 2001. The Registered Manger stated that they Company is in the process of changing the recruitment and selection documentation to include a medical declaration. This is currently separate from the application form and kept centrally. The staff records have recently been audited by the home and well organised and presented. 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 adult protection and physical intervention. The care staff working on the “ Phoenix unit” are registered nurses working with support workers . The staff are given the opportunity for training and there is a planned training programme for the home. Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 Page 17 All staff receive induction training and commence foundation training with 3 months of appointment. The Commission for Social Care Inspection received anonymous call from a member of staff expressing concern at the ratio of staff working on the “Phoenix” unit. On checking rotas for the last 4 weeks there had been a reduction in the 1:1 staffing from 4 to 3 for the service users who have funding for additional hours. The Registered Manager stated that this has been rectified. The home was carrying a few vacancies, which have now been filled. Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37 and 39… Quality in this out come area is good. This judgement has been made using the available evidence including a visit to this service. The home is generally well managed this could be further enhanced with effective quality assurance systems being implemented. EVIDENCE: The Registered Manager was appointed to the post in autumn 2005 and has now been registered with the Commission for Social Care Inspection. During the visit several staff were interviewed and stated that the changes being made were positive and for the benefit of the service users. The staff felt the atmosphere was better and although some staff were not happy with the changes and this has resulted in staff vacancies. The Registered Manager is in the process of reviewing the homes Statement Of Purpose and the aims and objectives. The Registered Manager has gained her Recognised Managers Award, and is interested in undertaking further training. The managing director and group care manger were present for part of the inspection and support the Registered Manager in her changes. The Registered Manager has implemented service user meetings and has used these to obtain their views on the changes to the home. Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 Page 19 The plans for the structural changes to the home have been agreed and the views of the service users as to what they would like has been obtained. No other form of quality assurance is carried out at present. The service users spoken with during the visit stated that they were happy at Shirebrook Manor. Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 Page 20 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 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No Score 6 2 7 2 8 X 10 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME 37 38 39 40 41 42 43 3 2 3 X 3 X 2 X X X X Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 Page 21 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 Assessment of all service users needs prior to admission must include information relating to the persons medical history daily needs and preferences. The services users assessment must be kept under review and revised when necessary. Care plans must include all service users identified needs, kept updated. Service users must be included in the planning process. All activities involving service users must be subject of a risk assessment. Any change to a service users’ health care plan must be recorded. The home must be suitable for the needs of the service users and be maintained both internally and externally. Staffing levels must be maintained to ensure services users health and welfare. An effective quality assurances system based on the service users’ views must be developed Timescale for action 31/07/06 2. 3. YA2 YA6 14 15 31/07/06 31/07/06 4 5 6 YA12 YA19 YA24 13 17 Schedule 3 23 31/07/06 31/07/06 31/08/06 7 8 YA33 YA39 18 39 31/07/06 31/07/06 Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 Page 22 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 4 5 Refer to Standard YA2 YA2 YA6 YA6 YA17 Good Practice Recommendations A copy of the care management assessment should be kept on each service user’s file The assessment should include all the areas listed in Standard 2.3.3. The service user or their representative should sign all care plans All service users should have an up to date risk assessment. This should include the removal of or addition of items relating to the service users environment Variations in menus should be recorded Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Shirebrook Manor Nursing Home DS0000002074.V294666.R01.S.doc Version 5.1 Page 24 - 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. 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