Inspection on 26/06/06 for Florence Shipley

This inspection was carried out on 26th June 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 but made no statutory requirements on the home.

Other inspections for this house

Florence Shipley 07/06/07

Florence Shipley 19/01/06

Florence Shipley 04/01/05

Florence Shipley 28/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Florence Shipley Florence Shipley Market Place Heanor Derbyshire DE75 7AA Lead Inspector Denise Bate Key Unannounced Inspection 26th June 2006 09:15 X10015.doc Version 1.40 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 Florence Shipley DS0000035583.V298614.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 Older People. 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. Florence Shipley DS0000035583.V298614.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Florence Shipley Address Florence Shipley Market Place Heanor Derbyshire DE75 7AA 01773 728400 01773 728405 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) Derbyshire County Council Mrs Eileen Wathall Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Florence Shipley DS0000035583.V298614.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 Brief Description of the Service: The home is situated within the community of Heanor, located at the market place, in the town centre. This establishment is a 26 bedded home with single rooms, but no en suite facilities. The home is pre-existing April 2002, therefore the references to pre-existing homes within the National Minimum Standards, are applicable. It is spread over three floors and with a lift to help access to the upper floors and a call system throughout the building in case of emergencies. There are assisted bathroom and toilet facilities on all floors and the home has three lounge areas on the ground floor and a dining room. The home has a large garden although access to this is not easy for residents. Fees are £364 per week for permanent service users, but a range of prices for short term care service users. Florence Shipley DS0000035583.V298614.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over six and a half hours. During the inspection 6 service users, 4 relatives, and 2 staff members were spoken with. The manager and 2 deputy managers were present during the inspection and provided assistance and information. Written information was provided by the manager prior to the inspection. Some service user surveys were also received A number of records were examined, including risk assessments and care plans, health and safety documentation, staff files, medication records and Regulation 26 visit records. An assessment was also made of the progress by the registered persons to address requirements made at previous inspections. Four service users were case tracked. A tour of the part of the building took place. What the service does well: What has improved since the last inspection? The home continues to meet the high standards evidenced at previous inspections. Some decoration has taken place in the communal areas of the home and some of the bedrooms. Florence Shipley DS0000035583.V298614.R01.S.doc Version 5.2 Page 6 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. Florence Shipley DS0000035583.V298614.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Florence Shipley DS0000035583.V298614.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home have a system for assessing service users’ needs to ensure that the care provided can meet service users’ needs appropriately. EVIDENCE: Several service users had looked at other homes and had made a very positive choice to live at Florence Shipley. Comments indicated that the home had more than lived up to their expectations. Relatives and service users indicated that information had been provided both at the time of moving in and at reviews. The Statement of Purpose and Service User Guide was available in the reception area and in the lounges. Florence Shipley DS0000035583.V298614.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans relating to personal and social care needs of service users are satisfactory. Service users are encouraged and supported to be independent and to exercise choice in all aspects of the home and are treated with dignity and respect. This contributes to the enhancement of service users’ everyday lives. EVIDENCE: All case tracked service users had personal development plans, daily logs, assessment forms for nutrition and tissue viability, risk assessments, monthly summaries, and monitoring forms e.g. heath professional visits, etc. Service users had signed documentation indicating that care plans had been discussed with them, and there was some evidence of regular reviews. Information was recorded in detailed daily logs. In some instances the personal service plan Florence Shipley DS0000035583.V298614.R01.S.doc Version 5.2 Page 10 could be more detailed and updated where a service users needs have changed (as detailed in the Statement of Purpose). There were some inconsistencies, not all files had up to date front sheets and some assessments were incomplete or not signed and dated. The manager indicated that she would rectify this and do her own audit of care planning documentation to ensure consistency. Several individual service users’ circumstances were discussed. Some recent reassessments indicated that some service users could have their needs met more appropriately in a nursing care setting. Service users’ health needs are recorded on personal service plans and on other monitoring documents within the care planning documentation. It was reported that a good relationship exists with local GPs and with District Nurses. The administration of medication was inspected and records found to be satisfactory. The inspector was informed that the pharmacist had visited recently and carried out a satisfactory inventory of the home’s medication storage and administration, and this report was made available. The home has a separate medication room with the medicines trolly, fridge and controlled medication cupboard. Derbyshire County Council have recently introduced a new medicines code for their residential homes. A copy of the latest advice from the Royal Pharmaceutical Society was available. Some service users are able to administer their own medication, which is kept securely in their rooms. Service users spoke very positively about staff and said they were treated with dignity and respect. One service user commented that Florence Shipley was ‘a real home from home’. Confirmation was given that they are given choice and are able to follow their own routines. Information from service user questionnaires stressed the availability of choice, the responsiveness of staff, and the availability of the management team to deal with queries or concerns. Information about likes and dislikes, and preferred routines are recorded on personal service plans. The home have an equal opportunities policy and staff and the manager had an understanding of disability, cultural and gender issues. Several individual circumstances were discussed with staff and service users where the home had displayed understanding and sensitivity relating to these issues. Florence Shipley DS0000035583.V298614.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities are provided that suit the expressed preferences of service users. Regular outside contacts are encouraged and supported. This assists in contributing to a pleasant atmosphere and the overall high level of satisfaction for service users. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users’ tastes and choices. EVIDENCE: The home have recently obtained a designated member of staff to run activities. Regular activities include movement and music, outings, in house entertainment, bingo and regular religious services. Details of forthcoming events, photographs of previous outings and events, and other information useful to service users and relatives/friends are displayed in the main entrance area. Service users interviewed reported that they felt the home provided suitable activities and catered for their interests. The care planning documentation for Florence Shipley DS0000035583.V298614.R01.S.doc Version 5.2 Page 12 individuals could detail service users interests and involvement in activities in more detail. Outings are being arranged over the summer and are very popular, service users are sometimes accompanied by relatives. A trip had been arranged to Skegness on the Thursday after the inspection. There is a regular residents meeting and the minutes of meetings were made available to the inspector. This was well attended and indicated that service users were given the opportunity to give their views on a variety of topics relating to the day to day running of the home. Relatives and friends of service users are involved in the home in a variety of ways and those spoken to confirmed that visitors to the home are welcomed. Most service users have regular contact with relatives and friends and some go out on a regular basis. Service users indicated that they feel staff are approachable and any problems can be discussed with them or with one of the managers. All indicated that they are able to exercise choice about aspects of their daily lives. Service users spoken to and feedback from questionnaires were extremely complimentary about the standard of catering, and the choice of menus that are available. Several instances were given where special diets or cultural preferences were catered for. Meals were attractively presented in a pleasant dining area. Florence Shipley DS0000035583.V298614.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are systems in place which promote the protection of service users from abuse and neglect. A complaints procedure is in place. EVIDENCE: There is a corporate complaints procedure in place, although most relatives and service users prefer to raise issues on a more informal basis. The complaints procedure is clearly displayed in the foyer and service user questionnaires indicated an awareness of the formal complaints procedure. The manager and staff are viewed as approachable and responsive. There have been no formal complaints recorded. Derbyshire County Council has clear procedures for dealing with the safety of service users and protecting them from harm. Staff had training in adult protection. Staff spoken to had had training in the protection of vulnerable adults and showed an awareness of adult protection issues and would pass any concerns on to their line manager. Florence Shipley DS0000035583.V298614.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment within the home is generally well maintained and provides service users with an attractive and homely place to live. EVIDENCE: The building provides service users with a comfortable and homely place to live with a variety of communal spaces situated in the front area of the building offering a choice of seating arrangements for service users. The dining areas are pleasant and spacious. The building has continued to be generally maintained to a good standard overall, apart from matters identified in the requirements. There is a rolling programme for maintenance and redecoration and the manager has a clear plan of priorities. Florence Shipley DS0000035583.V298614.R01.S.doc Version 5.2 Page 15 Some toilets and bathrooms were seen and found to be satisfactory, apart from the first floor bathroom. Service users said they were satisfied with their bedrooms, and several bedrooms were seen. These were pleasant and had been personalised. Some of the bedroom chairs were slightly worn and are in the process of being replaced. Most service users preferred to spend time communally during the day, but some had televisions in their bedrooms which they watched in the evening. There is a pleasant garden area where service users can sit in fine weather. Florence Shipley DS0000035583.V298614.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A trained and competent workforce are in place which meet the dependency needs of service users currently accommodated within the home. EVIDENCE: Staff had been coping with several residents who have been reassessed and moved to nursing care, quite pressured. Stressed the importance of good assessment prior to moving to home. The staff rotas were made available and found to provide adequate staffing to meet service users’ needs at the current time, although staff were often very busy. Staff had been looking after several residents who have been reassessed and as needing nursing care, and during this period of time had felt quite pressured. Staff were aware of and stressed the importance of good assessment of service users prior to them moving to home. There is a stable and long standing staff team, and this continuity was appreciated and commented on by service users and relatives. Continued care will be needed to ensure that staffing levels continue to meet service users’ Florence Shipley DS0000035583.V298614.R01.S.doc Version 5.2 Page 17 needs as current service users become more dependent. It is anticipated that staffing rotas will be looked at again at future inspections. The manager said that staff worked well as a team and were helpful, flexible and supportive. Staff spoken to were responsible, committed and competent. There is a team approach to work. Staff said they feel supported by both their colleagues and their managers, and felt that they were offered good training opportunities. Thorough induction training had taken place, including shadowing more experienced staff, and this was seen as helpful and contributing to staff job satisfaction. Staff files seen had evidence of CRB checks, copies of contracts and references. Derbyshire County Council has a thorough and detailed recruitment and selection procedure. Florence Shipley DS0000035583.V298614.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager provides clear leadership throughout the home with staff demonstrating an awareness of their roles and responsibilities ensuring that the home is run in the best interests of the service users. EVIDENCE: Service users and staff spoke positively about the manager and the management team. The unit manager has overall responsibility for the planning and development of the home. Three deputies have responsibility for daily operations and have their own areas to manage. Florence Shipley DS0000035583.V298614.R01.S.doc Version 5.2 Page 19 The home is visited regularly by a representative of the registered person and Regulation 26 visit reports were made available to the inspector. These indicated that matters of day to day management are dealt with, and service users and staff spoken to on a regular basis. Several reports featured a detailed look at particular aspects of the home. There had been a quality assurance exercise which indicated that the service provided by the home has been rated as good or excellent by 96 of service users and relatives. The results of the survey have been made available to service users. The inspector was informed that the home is moving towards a computerised system for managing service users’ finances. At present service users monies are kept in the safe and manual records kept, which appears to work satisfactorily. The manager said an advocacy service is used by service users when they have no family or friend to advocate for them. Staff confirmed that they have regular supervision. Information on maintenance and health and safety records was provided by the manager in the pre-inspection questionnaire and indicate that, apart from the electrical hard wiring certificate, matters pertaining to maintenance and health and safety are satisfactory. The electrical hard wiring certificate indicates that some electrical work needs to be carried out. Standards of cleanliness are extremely high, and this was commented on by both service users and relatives, as well as being observed on the day of inspection. Florence Shipley DS0000035583.V298614.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X 3 x 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 Florence Shipley DS0000035583.V298614.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? yes 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. 2. 3. 4 Standard OP21 OP19 OP24 OP38 Regulation 23(2)(b) 23 (2) (b) 23(2)(c) 23 (2) (b) Requirement First floor toilet and disabled toilet require upgrading Exterior decoration must take place to areas outside the dining room. Some furniture in bedrooms requires upgrading. A satisfactory programme for carrying out work identified on the recently electrical hard wiring certificate must be drawn up and a copy sent to CSCI. Timescale for action 01/09/06 01/09/06 01/09/06 01/09/06 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 OP7 OP19 Good Practice Recommendations Care plans should be audited to ensure consistency. Some areas of the kitchen should be upgraded, including the cupboards and floor covering around the dishwasher. DS0000035583.V298614.R01.S.doc Version 5.2 Page 22 Florence Shipley 3. 4. OP23 OP27 New security fencing or alternative arrangements should be put in place around the garden. Service user dependency should continue to be monitored to ensure staffing levels continue to meet service users needs. Florence Shipley DS0000035583.V298614.R01.S.doc Version 5.2 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 Florence Shipley DS0000035583.V298614.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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