CARE HOME ADULTS 18-65
Shirebrook Manor Nursing Home Central Drive Shirebrook Nottinghamshire NG20 8BA Lead Inspector
Stuart Hannay Unannounced Inspection 24th February 2006 09:30 Shirebrook Manor Nursing Home DS0000002074.V283786.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.V283786.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.V283786.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.V283786.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 31st August 2005 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.V283786.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection lasted for 5 hours; the acting manager, her line manager, care staff and service users were interviewed. A range of records was checked, relating to care and health and safety. A brief inspection was made of the building. What the service does well: What has improved since the last inspection? What they could do better:
The manager said that the home is in the process of implementing a new care planning system which should address the issues around care plans identified in the previous inspection. In order to ensure that service users and staff get the full support they need and that staffing is maintained at the established levels on the ‘Phoenix’ unit, the home must continue to ensure that staffing issues are addressed. Some staff interviewed felt this was having an effect on staff morale. The home also needs to fully implement its staff supervision
Shirebrook Manor Nursing Home DS0000002074.V283786.R01.S.doc Version 5.1 Page 6 programme and some induction records checked had not been fully signed and dated. 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.V283786.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.V283786.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): EVIDENCE: These standards were not checked during the current inspection. Shirebrook Manor Nursing Home DS0000002074.V283786.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): 6 The home is still in the process of upgrading the care planning system to address requirements identified in the previous report where it was identified that ‘the delivery of care may be compromised due to inconsistent record keeping’. EVIDENCE: The manager stated that a new care planning system is being implemented in order to address the shortcomings identified in the previous report where “it was recognised that the records of each individual was stored in different files, in different filing cabinets and in different areas of the home. Some of the prescriptions of care were documented with the profiles rather than the care plans, which may lead to errors. It was agreed that to be able to have an easy reference document looking holistically at the service user would be beneficial to the service users, staff and other professionals who may need the information at case reviews etc, and would help to reduce the possibility of duplication and errors”. Progress with the care planning systems will be checked on the next inspection.
Shirebrook Manor Nursing Home DS0000002074.V283786.R01.S.doc Version 5.1 Page 10 Shirebrook Manor Nursing Home DS0000002074.V283786.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 There are appropriate activities taking place in the home to stimulate and entertain the service users. There are specialist facilities provided for people with severe disabilities. Service users take advantage of local facilities. EVIDENCE: The manager has introduced a more structured day to ensure that staff engage in activities with service users. During the inspection, staff were doing activities and playing games with service users. These included manicures and reflexology, playing skittles, reading with people or sitting talking with them. Some service users were also going out on trips with staff on the day of the inspection. Staff spoken with said that more was made of the specialist areas such as the Snoozelen room and soft play areas. Activities need to be quite specifically targeted as the range of disabilities is very wide at the home. Some staff spoken with from the ‘Phoenix’ unit felt that they had been able to do less activities with service users in recent months as they had been working with 3 staff members for 5 service users instead of 4 staff members. Shirebrook Manor Nursing Home DS0000002074.V283786.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): 18 19 Service users who were able to express themselves verbally said that their needs were met by staff. All service users looked well cared for and interaction between staff and service users was relaxed and respectful. EVIDENCE: Many of the service users do not express themselves verbally but 3 people 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 looked clean and were dressed in age appropriate clothing. Those service users who were less able to express themselves verbally looked relaxed in the company of staff, holding hands or sitting with them on the settees, talking or watching television. It was identified in the previous inspection that “extensive individual assessments were undertaken on each service user, and care plans drawn up. These care plans were extensive and included profile documents, prescriptions of care by a qualified nurse, individual assessed needs, proposed intervention to meet these needs and risk assessments”. Shirebrook Manor Nursing Home DS0000002074.V283786.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): 22 The manager was aware of the adult protection procedures and had recently used these to identify concerns. EVIDENCE: Two recent adult protection issues had been raised at the home in recent months and had been referred according to the appropriate procedures. The Commission for Social Care Inspection had also been informed of progress with these. Shirebrook Manor Nursing Home DS0000002074.V283786.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): 24 30 The home was generally clean, well-maintained and reasonably decorated. The systems for reporting and logging repairs is now improved. EVIDENCE: Building issues identified in the previous report had mostly been addressed. The manager said that screens had now been provided in every double room. A number of bedrooms had been redecorated and 4 bedrooms checked were clean, tidy and decorated to a good standard. As identified in the previous report, a number of bedrooms did not have curtains and the taps on some washbasins had been disabled or locked. It was identified that this was in the service users’ interests due to personal preference or health and safety issues. It was stated that this needed to be recorded in the individual’s care plans, however the manager said that this had yet to be done and would be included as part of the new care planning format. One issue not checked from the previous report was the “taps on the hand washbasin [in Room 28]were very stiff and difficult to operate. The water had difficulty in draining from the washbasin into the waste pipe”. This will be checked on a later inspection.
Shirebrook Manor Nursing Home DS0000002074.V283786.R01.S.doc Version 5.1 Page 15 The manager and the regional manager confirmed that the reporting system for logging repairs is now being used more effectively. In contrast with the rest of the building, the ‘Phoenix’ unit was less bright and pleasant. A number of reasons mitigate against being able to provide certain furnishings as many of the service users find certain things over-stimulating or distressing and will remove or damage them. However, the manager said that she is looking of ways of being able to improve the environment as much as possible this before the planned move to more suitable premises. Shirebrook Manor Nursing Home DS0000002074.V283786.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): 32 34 36 There were generally sufficient staff on duty at the home – the levels on the ‘Phoenix’ unit need to be kept under review. Staff had received a range of training and recruitment checks had been made on staff. A supervision and appraisal system has been established for staff. EVIDENCE: The manager said that there were generally 6 care staff and 1 or 2 qualified nurses on duty at the home between 8 a.m. and 8 p.m. At nights there was 1 qualified nurse and 4 care staff. She stated that these numbers were lower than on the previous report as an additional carer was being employed to provide one-to-one care for a service user who was no longer at the home. The rota for the ‘Phoenix’ unit showed that on regular occasions since the beginning of January 2006, there were 3 staff, instead of 4, working with the service users. This unit generally provides a service for people who present more challenging behaviours. Whilst there did not appear to be any immediate health and safety or welfare concerns related to this, some staff spoken with said that it made doing activities with service users more difficult and was responsible for ‘low morale’ on the unit. The manager and the regional manager said that a permanent member of the team was currently suspended and that it was not always possible to cover this at present. However, they said were working towards ensuring that 4 staff would be deployed in this part of the home. A system of regular staff supervision has just been started and will be monitored on subsequent inspections. The recruitment records of 2 staff
Shirebrook Manor Nursing Home DS0000002074.V283786.R01.S.doc Version 5.1 Page 17 members were checked and these contained all the required information. They both had clear Criminal Records Bureau and POVA checks. Shirebrook Manor Nursing Home DS0000002074.V283786.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): 37 38 41 42 43 Staff generally felt that the new manager was approachable and supportive and acted in the best interests of the service users. No health and safety issues were noted in the home. The service is audited and supported by its line manager. EVIDENCE: The current manager was appointed in Autumn 2005 and is not yet registered with the Commission for Social Care Inspection. Staff interviewed and spoken with generally felt that there were more focus on the service users and their needs since the appointment of the new manager. It was clear that the activities had improved at the home since she started and she has identified, with the assistance of the regional manager, which areas of the service need improvement or consolidation. As noted above, some staff felt that morale was low in a particular part of the home and did not feel that some of the changes had been positive. Opportunities were available for them to express their opinions in staff meetings and one-to-one sessions and the management team were aware of these sentiments. The fire alarm system, according to the records seen, had been checked on a regular basis since the previous
Shirebrook Manor Nursing Home DS0000002074.V283786.R01.S.doc Version 5.1 Page 19 inspection. Certificates were not available to confirm that the nurse call system had been checked, however the records indicated that service engineers had visited in the previous 12 months. One staff member’s induction sheet was checked to see if she had had fire safety training. This had been ticked off the list but there was no date to show when the training had taken place or who had signed that she was competent in this area. Shirebrook Manor Nursing Home DS0000002074.V283786.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 X 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 X 23 3 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 3 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 3 3 X X 2 3 3 Shirebrook Manor Nursing Home DS0000002074.V283786.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 YA6 Regulation 12 Timescale for action The registered person must 30/06/06 ensure that the documentation is sufficient to provide a full and clear prescription of care and intervention, so that adequate care can be provided. This to include risk assessments and records relating to the removal of or addition of items or facilities. Previous timescale: 30/9/05 The registered person must 30/08/06 ensure that the home has a registered manager. Previous timescale: 30/11/05 All entries in the staff induction 30/06/06 programme must be signed and dated to show when training has taken place and who has assessed the person as competent. The staff supervision and 30/07/06 appraisal programme must be fully implemented. Requirement 2 YA32 8 3 YA42 18 (a) 4 YA36 18 (2) Shirebrook Manor Nursing Home DS0000002074.V283786.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 Refer to Standard YA18 YA24 Good Practice Recommendations The home should ensure that the staffing allocation on the Phoenix unit is kept under review and further staff deployed if necessary. The home should find ways of enhancing the environment in the Phoenix unit. Shirebrook Manor Nursing Home DS0000002074.V283786.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
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