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Inspection on 31/08/05 for Shirebrook Manor Nursing Home

Also see our care home review for Shirebrook Manor Nursing Home for more information

This inspection was carried out on 31st August 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provided care for a group of heavily dependent often demanding and challenging individuals. The assessments and other record keeping in some areas were quite extensive. Extensive contracts were in place. The number of staff was up lifted to meet the contracted extra input for some individual service users.

What has improved since the last inspection?

There was full compliance to the previous requirements.

What the care home could do better:

The maintenance within the building could be considerably improved alongside the communication system relating to the repairs. The day care and other therapy room could be more extensively utilised. A registered manager should be in post, although the inspector appreciated that the director had this process `in hand` and intended to submit an application in the near future. The home should comply with the requirements of this inspection.

CARE HOME ADULTS 18-65 Shirebrook Manor Nursing Home Central Drive Shirebrook Nottinghamshire NG20 8BA Lead Inspector Ivan Barker Unannounced 31 August 2005, 12.00pm st The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Shirebrook Manor Nursing Home C02 C52 S2074 Shirebrook Manor V247916 310805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Shirebrook Manor Nursing Home Address Central Drive Shirebrook Nottinghamshire NG20 8BA 01623 744414 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Shirebrook Manor Nursing Home Limited Vacant Care Home with Nursing 33 Category(ies) of Learning Disabilty - 33 registration, with number of places Shirebrook Manor Nursing Home C02 C52 S2074 Shirebrook Manor V247916 310805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 31/01/05 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 C02 C52 S2074 Shirebrook Manor V247916 310805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Only a limited number of the National Minimum Standards were examined at this inspection (with emphasis on several of the ‘key standards’). However, even from examination of prioritised standards, a number of requirements have been raised. The persons present at the inspection were: Mr S Sunderland, Director Mrs S Radford, Acting manager. (Currently the Region manager) Within this inspection, which occurred over a four-hour period, the inspector toured the building, spoke to service users, and staff and examined the care plans and other documentation. He spoke with 7 service users and 3 staff; unfortunately no relatives or visitors were present during the inspection. Although the need for activities was briefly mentioned within this report, this area will be assessed more extensively on the next inspection. The inspector has received verbal assurance from Mr Sunderland and Mrs Radford that all issues raised within this report will be acted upon. The inspector would wish to the director, acting manager staff and service users for their full cooperation during the inspection. What the service does well: The home provided care for a group of heavily dependent often demanding and challenging individuals. The assessments and other record keeping in some areas were quite extensive. Extensive contracts were in place. The number of staff was up lifted to meet the contracted extra input for some individual service users. Shirebrook Manor Nursing Home C02 C52 S2074 Shirebrook Manor V247916 310805 Stage 4.doc Version 1.40 Page 6 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 contacting your local CSCI office. Shirebrook Manor Nursing Home C02 C52 S2074 Shirebrook Manor V247916 310805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Shirebrook Manor Nursing Home C02 C52 S2074 Shirebrook Manor V247916 310805 Stage 4.doc Version 1.40 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 standard(s) 5 Individual contracts will form a basis for all parties to be aware of the expected provision of either personal or nursing care and the service provision. EVIDENCE: A package of care was agreed with the Health or Social Services contracting unit. The contracting units draw up the individual service user’s contract. The contracting unit and home have input into the content of the contract. The home’s contracts met the required standards. The director advised that the service user and or their relative were shown a copy of the contract. The documents were kept in the office for safekeeping, and available on request. Shirebrook Manor Nursing Home C02 C52 S2074 Shirebrook Manor V247916 310805 Stage 4.doc Version 1.40 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 standard(s) 6 The delivery of care may be compromised due to inconsistent record keeping. EVIDENCE: 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. The plans were drawn up following consultation with other professionals, the family and the service user, and reviewed on a daily, and monthly basis by the nurses and at the six monthly reviews, in consultation with other professionals. However 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 Shirebrook Manor Nursing Home C02 C52 S2074 Shirebrook Manor V247916 310805 Stage 4.doc Version 1.40 Page 10 and other professionals who may need the information at case reviews etc, and would help to reduce the possibility of duplication and errors. Shirebrook Manor Nursing Home C02 C52 S2074 Shirebrook Manor V247916 310805 Stage 4.doc Version 1.40 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 standard(s) 0 EVIDENCE: These standards were not assessed, at this inspection. Shirebrook Manor Nursing Home C02 C52 S2074 Shirebrook Manor V247916 310805 Stage 4.doc Version 1.40 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 standard(s) 0 EVIDENCE: These standards were not assessed at this inspection. Shirebrook Manor Nursing Home C02 C52 S2074 Shirebrook Manor V247916 310805 Stage 4.doc Version 1.40 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 standard(s) 0 EVIDENCE: These standards were not assessed at this inspection. Shirebrook Manor Nursing Home C02 C52 S2074 Shirebrook Manor V247916 310805 Stage 4.doc Version 1.40 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 standard(s) 24,26,30. The standard of decoration and maintenance was poor, in some areas of the home. Much of these shortfalls may be because of factors relating to the staff, i.e. none reporting of repairs. The delivery of care may be compromised due to inconsistent record keeping. EVIDENCE: The previous requirements relating to the environment were examined and all the requirements had been acted upon and resolved. On touring the building, the inspectors found the following: A double room on the 1st floor was without screens, to provide privacy. The acting manager informed the inspector that she would purchase the screens. Within room 28, the taps on the hand washbasin were very stiff and difficult to operate. The water had difficulty in draining from the washbasin into the waste pipe. Shirebrook Manor Nursing Home C02 C52 S2074 Shirebrook Manor V247916 310805 Stage 4.doc Version 1.40 Page 15 Within room 31 there was a strong unpleasant odour. It was difficult to establish the source of the odour, whether it was from the carpet or other furniture within the room. Several bedroom walls within the home had small areas of damage and required repair and redecoration. Within a bedroom there was a large area of plaster, approximately 30cm x 30cm, missing from the wall. The director informed the inspector that the service user had damaged the area and the repair was difficult to complete as the service user remained in his room for most of the day. However it had been planned that the service user was taken out for the day to allow the plasterers access to the room. Also the doorframe to the room was damaged and the door was loose on the hinges. The director again advised the inspector that this was because of the service user’s challenging behaviour and that the service user had on several occasions removed the door from the frame, and that this area was to receive attention, at the same time as the wall. The door to the toilet, opposite room 2, could not be opened. On further investigation it was established that the hinges on the frame were not connected to the door. The inspector was advised that another service user had pulled the door from the frame. Some rooms had no curtains to the windows. The inspector discussed the lack of curtains with one of the service users, who resided within one of these rooms. He informed the inspector that he would ‘Rip them down, don’t like curtains’. The director informed the inspector that where the curtains were not fitted, then a plastic opaque film had been fitted to the window to ensure the service user’s privacy. Within several rooms the operating mechanism of the tap in the washbasin had been removed, and some of the wardrobes had clasps and padlocks fitted. The inspector was informed that these interventions were necessary because of the type of service user being cared for within these rooms. The inspector questioned if the issues of the lack of curtains, removal of tap mechanisms and the addition of clasps and locks was recorded within the individuals care plans. The director and acting manager were unable to confirm that all these issues had been recorded. The acting manager informed the inspector that as part of the review of the plans she would ensure that these issues were recorded and the reason for the lack of or the addition of such facilities would also be documented. On returning to the office the inspector examined the ‘Repair book’. None of the items listed above as repairs were recorded in the book. The director identified that he had a team of maintenance staff available, who regularly ring the home to check if there are any repairs. He and the inspector questioned Shirebrook Manor Nursing Home C02 C52 S2074 Shirebrook Manor V247916 310805 Stage 4.doc Version 1.40 Page 16 what was happening in the home. If the items were not being reported in the repair book then the maintenance staff were not being made aware of the problem. The director informed the inspector that he would address this issue to both the care and maintenance staff. The home had a ‘day care facility’ and a newly created therapy room on the first floor. Nether facilities were being used at the time of the visit. On discussing this fact with the staff, the inspector was informed that the facilities were used on an ‘ad–hoc’ basis. The inspector suggested that there could be more use of these facilities, and a structured programme and booking system would enhance the use of these facilities, particularly as the inspector observed some staff sat with service users in the lounges, but with little interaction occurring. The director again accepted this point and informed the inspector that he would be raising this with the staff. Shirebrook Manor Nursing Home C02 C52 S2074 Shirebrook Manor V247916 310805 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 Current staffing levels in place would appear to meet the current dependency needs of service users, accommodated within the home. However as previously express, there needs to be a re-examination of the therapy input. A registered manager was not in post. EVIDENCE: On examination of the staff rosters and with discussions with the director and acting manager the following was established. On the am shifts, there were 2 qualified nurses and 8 care assistants. On the pm shifts, there were 2 qualified nurses and 8 care assistants. On the night shifts, there were I qualified nurse and 4 care assistants. Plus, the acting manager. In should be noted that the number of staff was dependent on each individual’s contracting. 4 service users were on 1-1 supervision, during some of the day / evening time. Some service users were on 1-1 supervision for 1 hour, others for more than one hour. There was an acting manager in post. There needs to be a registered manager in post. The director informed the inspector that interviews had already Shirebrook Manor Nursing Home C02 C52 S2074 Shirebrook Manor V247916 310805 Stage 4.doc Version 1.40 Page 18 commenced and he hoped to submit an application to the Commission for Social Care Inspection by the end of the month. Shirebrook Manor Nursing Home C02 C52 S2074 Shirebrook Manor V247916 310805 Stage 4.doc Version 1.40 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 0 EVIDENCE: These standards were not assessed at this inspection. Shirebrook Manor Nursing Home C02 C52 S2074 Shirebrook Manor V247916 310805 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x 3 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 2 x x x 2 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x 2 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Shirebrook Manor Nursing Home Score x x x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x C02 C52 S2074 Shirebrook Manor V247916 310805 Stage 4.doc Version 1.40 Page 21 no 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 6 Regulation 12,14 Requirement Timescale for action 30/09/05 2. 24,26,30 3. 32 The registered person must 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 included risk assessments and records relating to the removal of or addition of items or facilities. 12, 16, 23 The registered person must ensure that the home is maintained to an adequate standard and that repairs and refurbishment are acted upon. 8 The registered person must ensure that the home has a registered manager. 30/11/05 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Shirebrook Manor Nursing Home C02 C52 S2074 Shirebrook Manor V247916 310805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection South Point, 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 C02 C52 S2074 Shirebrook Manor V247916 310805 Stage 4.doc Version 1.40 Page 23 - 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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