Inspection on 28/02/06 for Sheldon Ridge Nursing Home

This inspection was carried out on 28th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sheldon Ridge Nursing Home 26/05/09

Sheldon Ridge Nursing Home 13/01/09

Sheldon Ridge Nursing Home 16/01/08

Sheldon Ridge Nursing Home 09/03/07

Sheldon Ridge Nursing Home 27/06/06

Sheldon Ridge Nursing Home 09/08/05

Sheldon Ridge Nursing Home 09/02/05

Sheldon Ridge Nursing Home 11/08/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Sheldon Ridge Nursing Home 1/3 Bierley Lane Bradford West Yorkshire BD4 6AB Lead Inspector Carol Haj-Najafi Unannounced Inspection 28th February 2006 09:15 Sheldon Ridge Nursing Home DS0000019895.V265966.R01.S.doc Version 5.0 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 Sheldon Ridge Nursing Home DS0000019895.V265966.R01.S.doc Version 5.0 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. Sheldon Ridge Nursing Home DS0000019895.V265966.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sheldon Ridge Nursing Home Address 1/3 Bierley Lane Bradford West Yorkshire BD4 6AB 01274 688029 01274 684320 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) Brunel & Family Housing Association Limited Ms Susan Linda Roberts Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Sheldon Ridge Nursing Home DS0000019895.V265966.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2005 Brief Description of the Service: Sheldon Ridge is registered to provide long term nursing care for thirteen adults with a learning disability. The home is situated in the village of Bierley and is close to local amenities and a bus route.The home was originally two purpose built bungalows; an extension has linked the bungalows, and created additional communal space. All bedrooms provided are single accommodation. Spacious communal areas include lounges, dining areas, a multi-sensory room, and an activity room. The home has an attractive enclosed rear garden, with level access from the lounges. Specified parking areas are available for visitors to the home.Nursing staff, health care assistants, and domiciliary staff are employed at the home. The home is a joint venture between Brunel Support Works and Bradford District Health Trust. Sheldon Ridge Nursing Home DS0000019895.V265966.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced inspection between 09.15am to 03.15pm. The purpose of the inspection was to ensure the home was operating and being managed to a satisfactory standard. The inspector spoke to six staff and the registered manager. Service users living at the home have complex needs, and discussions with service users were very limited. Interaction between staff and service users was observed. Records were inspected including service user plans, risk assessments, daily records and health and safety records. Feedback was given to the registered manager at the end of the inspection. What the service does well: What has improved since the last inspection? What they could do better: The inspection revealed that generally service users are not receiving a good service. There are not enough staff to take service users out or spend enough time with service users in the home, this has resulted in service users spending long periods of time without staff input or any form of stimulation. The last inspection highlighted similar problems but staff and management acknowledged this is now much worse. The content of the care plans has improved but the manager now needs to look at how the plans can be followed consistently. The manager had already started planning how this could be improved. Sheldon Ridge Nursing Home DS0000019895.V265966.R01.S.doc Version 5.0 Page 6 The admission process is generally satisfactory but it is important to make sure all relevant information about service users is available. The amount that service users have been expected to pay for hiring a minibus, and would be expected to pay for a holiday is excessive. Further information on this matter must be sent into the CSCI. Requirements and recommendations identified at this inspection can be found at the end of this report. 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. Sheldon Ridge Nursing Home DS0000019895.V265966.R01.S.doc Version 5.0 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 Sheldon Ridge Nursing Home DS0000019895.V265966.R01.S.doc Version 5.0 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): 1, 2, 3 & 4 Service users have an opportunity to visit the home before they move in, and assessments are carried out but it was not possible to confirm that this is carried out satisfactorily because some information was not available. EVIDENCE: Two service users have moved into the home within the last year. Both admissions were looked at. The manager was responsible for co-ordinating the admissions. The manager spoke in detail about the most recent admission. She said the home’s brochure was sent to relatives. The manager visited the service user and the service user had opportunities to visit the home. A pre-admission assessment, which had been completed by the home, contained specific information about the service user’s needs. A comprehensive care management assessment had also been completed but a copy of this had not been given to the home until several weeks after the service user had moved in. This was then kept in a staff member’s file as they were devising the care plan, therefore it was not readily available for staff to read. If staff do not have access to information about a service user this could result in their needs not being met. Sheldon Ridge Nursing Home DS0000019895.V265966.R01.S.doc Version 5.0 Page 9 Although the manager spoke of a planned admission for the other service user no information was available, therefore it is not possible to confirm that the service user’s needs were properly assessed before admission. Sheldon Ridge Nursing Home DS0000019895.V265966.R01.S.doc Version 5.0 Page 10 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&9 Care plans have improved and there is some good information about how service users’ needs should be met but these are not consistently followed. Care plans would be more accessible if some of the old information was filtered out and archived. EVIDENCE: Since the last inspection care plans and risk assessments have been reviewed to make sure all the important information has been included. This process is nearly complete and the manager anticipates it will be finished by the end of March. Three care plans were looked at. Two plans had good information about service users’ needs and were reviewed regularly. One of the plans had a lot of historical information that does not need to be read on a regular basis. It was difficult to locate some information. The other care plan was out of date and had been completed by a home where the service user used to live. When a service user starts living in a new care setting, their needs should be re assessed and a new plan of care should be agreed. Sheldon Ridge Nursing Home DS0000019895.V265966.R01.S.doc Version 5.0 Page 11 Care plans and risk assessments are kept in a small office, and staff confirmed that these were not accessed on a regular basis. Staff also raised concerns that care plans identified how a service user’s needs should be met but these were not consistently followed. Examples of bathing and morning routines were given. It was also evident from daily records and staff discussions that activity and leisure plans were not implemented. The manager had already identified that the care plans were not being used as working documents and was exploring options for introducing a more streamlined system. Sheldon Ridge Nursing Home DS0000019895.V265966.R01.S.doc Version 5.0 Page 12 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, 15 & 16 Service users do not receive a satisfactory level of stimulation, hence their quality of life is poor. Contact with relatives is good. EVIDENCE: The inspector spoke to six staff and the manager, all of who agreed that activities and opportunities to go out should improve. Four weeks of daily records were looked at for three service users. Throughout this period there was no evidence that the service users had been involved in any regular activity. Occasional aromatherapy sessions were given and regular rides out on the minibus were provided. Service users have regular opportunities to go out on the minibus but staff confirmed that it is not very often that they get chance to get off the bus. Previously service users were able to have regular outings for meals, to the cinema, and shopping. But recently these have been very infrequent. The lack of activities and outings had been raised at the last two inspections; the majority of staff said poor activity provision had resulted in service users spending very long periods of time with no stimulation. The last report stated Sheldon Ridge Nursing Home DS0000019895.V265966.R01.S.doc Version 5.0 Page 13 that service users were sometimes left for long periods of time, without having staff input. Staff and the manager said insufficient staffing levels was the main reason why activities were not offered on a regular basis. More details of this have been written in this report under the staffing section. Staff also said there had been significant changes in the needs of one service user which had resulted in much more staff input. Only one service user attends any form of day care service and this is only for half a day a week. Staff said this has increased the amount of time that service users were not stimulated. Recent staff meeting minutes confirmed that service users are not able to go on holiday. In addition to the cost of the holiday for the service user and staff and any spending money, service users have to pay for staff overtime. An invoice for staff overtime for one staff from Monday to Friday had exceeded £500. The manager said nearly all the service users could not afford to pay these costs therefore could not go on holiday. Staff said they encourage family involvement and they talked about consulting service user’s relatives before making decisions. Daily records stated that some relatives visit the home on a regular basis. Sheldon Ridge Nursing Home DS0000019895.V265966.R01.S.doc Version 5.0 Page 14 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 & 20 Staff make sure health and personal care needs are met, and any health concerns are carefully monitored. Although medication systems are well organised, not all medication is administered properly. EVIDENCE: Staff said service users health and personal care needs are met. Daily records confirmed that service users regularly have baths and showers. It was also evident that any concerns about health were quickly acted upon and health care appointments were followed up. Medication systems were looked at. Qualified staff are responsible for administering medication. Storage of medicines was tidy and well organised. Administration records and regular medication which is presented in blister packs were looked at. These appeared to have been administered and signed for correctly. One service user had been prescribed a short course of antibiotics. Originally twenty tablets had been prescribed, eighteen tablets were in the bottle, four should have been administered, and only three had been signed for. The number of tablets had not been checked on receipt. Sheldon Ridge Nursing Home DS0000019895.V265966.R01.S.doc Version 5.0 Page 15 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 & 23 Systems should be introduced to ensure service users’ finances are protected and any payments should be obtained through a full consultation process. The charge for the hire of a vehicle seems very excessive. EVIDENCE: Previous inspections have identified that a complaint’s procedure does not include details of the Commission for Social Care Inspection. Therefore any complainants would not be aware that they could contact the commission if they were unhappy with how their complaint was investigated. The registered manager confirmed this is due be updated in June 2006. Service users pay a monthly contribution to transport. In addition to the monthly payment, an invoice for £17,000 had been sent to the home for a vehicle that was leased between spring and September. It was several months after the vehicle was hired that notification of the cost of the vehicle was sent to the home. The manager said she was informed that service users had to pay the invoice two weeks before it was sent out and the £17,000 had been equally divided between the thirteen service users. The manager confirmed that payment had not been discussed or agreed with service users or their representatives before the vehicle was leased. This is not good practice. Sheldon Ridge Nursing Home DS0000019895.V265966.R01.S.doc Version 5.0 Page 16 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): EVIDENCE: Standards from this section were not looked at during this inspection. Sheldon Ridge Nursing Home DS0000019895.V265966.R01.S.doc Version 5.0 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 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, 33 & 34 The home does not have enough staff to meet service users’ needs. This has been an ongoing problem and must be addressed. Staff are unhappy with the standard of care provided at the home and this has affected team morale. Staff are given opportunities to attend training which is specific to the needs of those living at the home. EVIDENCE: All staff raised concerns about the quality of service. Most staff were very disappointed and frustrated at how the service has changed and how service users quality of life has deteriorated. Several staff said ‘staff morale was low’. The last inspection identified that it was sometimes not possible to organise group or individual activities and service users were sometimes left for long periods of time, without having staff input. Staff said the provision of activities was even less, and staff time with service users had been reduced further. Two activity workers who were specifically employed to organise and provide activities had been covering shifts because there were insufficient staff working at the home, this has had negative implications on service users. A cook is employed to work four days a week. Care staff work in the kitchen for the other three days. And although agency workers cover the care hours, a cook Sheldon Ridge Nursing Home DS0000019895.V265966.R01.S.doc Version 5.0 Page 18 employed for the three days or an agency cook would release the permanent care staff to work directly with service users. No staff have been recruited to work at the home within the past year but staff have transferred from other homes managed by Bradford District Care Trust. Staff transferring visit the home and have a meeting with the manager. The manager said any unsuitable candidates would not be offered a post. Information about staff that have transferred has not been given to the home. The manager has updated staff training records. Some staff are completing NVQ level 2 and training sessions are arranged for staff which are specific to the needs of service users living at the home. Regular staff meetings are held but sometimes attendance is poor, it was suggested that more notice for meetings could improve attendance. Sheldon Ridge Nursing Home DS0000019895.V265966.R01.S.doc Version 5.0 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 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, 39, 41, 42 & 43 The registered provider has failed to take appropriate action to address some key requirements, therefore the overall management of the service, which is external to the home, is not fulfilling its responsibilities. The issues continue to affect the care that is provided. Regular health and safety checks are carried out. A good system is in place for monitoring incidents. EVIDENCE: The registered manager has been in post for two and a half years. She is a registered nurse (learning disabilities) and has achieved the registered manager’s award and the NVQ assessor’s award. There were clear indications that the staff team and the manager were going through a stressful and difficult period. The management structure has been temporarily altered, leaving the manager without a deputy. The registered provider is Brunel Housing and they are responsible for ensuring the home meets the national minimum standards and the care homes Sheldon Ridge Nursing Home DS0000019895.V265966.R01.S.doc Version 5.0 Page 20 regulations. Issues were raised at this inspection and previous inspections about staffing levels and insufficient activities. The regulation 26 visit report on the 15th February stated that staffing levels had been raised as a concern. A quality monitoring survey was sent out to relatives some time ago. Another one is due to be sent out in April. The manager monitors responses. Several health and safety records were looked at. These were signed to confirm they had been checked in line with policies and procedures. Incident forms were also looked at. These had been completed with sufficient detail. The manager has monitoring system that ensures appropriate action is taken to minimise incidents reoccurring. Sheldon Ridge Nursing Home DS0000019895.V265966.R01.S.doc Version 5.0 Page 21 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 3 3 2 3 X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 2 13 1 14 1 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 1 2 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sheldon Ridge Nursing Home Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 1 X 3 X 3 3 1 DS0000019895.V265966.R01.S.doc Version 5.0 Page 22 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 15 Requirement The registered manager must ensure service users have an up to date plan that covers social, personal and health care needs. The plans should be followed to make sure service users’ needs are met. (Timescale of 31/12/05 not met) The registered provider must ensure service users are given opportunities to access the community. (Timescale of 30/09/05 not met) The registered manager must ensure service users have oportunities to engage in recreational activities. (Timescale of 30/09/05 not met) The registered manager must ensure service users receive medication as prescribed. The registered provider must ensure details of the CSCI are included in the complaints procedure (Timescale of 31/10/04, 31/03/05 & 31/10/05 not met) The manager must forward copies of financial records relating to transport and hire DS0000019895.V265966.R01.S.doc Timescale for action 31/03/06 2 YA13 16 30/04/06 3 YA14 16 30/04/06 4 5 YA20 YA22 13 22 31/03/06 30/06/06 6 YA23 17 31/03/06 Sheldon Ridge Nursing Home Version 5.0 Page 23 vehicles to the CSCI. 7 YA33 18 The registered provider must 31/03/06 ensure there are adequate staff on shift to meet the needs of service users; this must include appropriate cover for domicilairy duties. (Timescale of 30/09/05 not met) The registered provider must 30/04/06 ensure staff records are held in the home. The registered provider must 31/03/06 ensure the external management of the home enables the registered manager to provide a service that meets the needs of the service users. 8 9 YA34 YA43 17 10 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 YA3 YA14 Good Practice Recommendations The registered manager should make sure assessments are available. The registered provider should ensure service users have the opportunity to have an annual holiday. Sheldon Ridge Nursing Home DS0000019895.V265966.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. 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