Inspection on 11/04/06 for Shelton Lock Nursing Home

This inspection was carried out on 11th April 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Shelton Lock Nursing Home 31/07/08

Shelton Lock Nursing Home 26/07/07

Shelton Lock Nursing Home 01/12/05

Shelton Lock Nursing Home 09/08/05

Shelton Lock Nursing Home 08/03/05

Shelton Lock Nursing Home 29/07/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Shelton Lock Nursing Home 61a Weston Park Avenue Shelton Lock Derby DE24 9ER Lead Inspector Unannounced Inspection 24th April 2006 11:00 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 Shelton Lock Nursing Home DS0000002147.V291525.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 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. Shelton Lock Nursing Home DS0000002147.V291525.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Shelton Lock Nursing Home Address 61a Weston Park Avenue Shelton Lock Derby DE24 9ER 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) 01332 690606 01332 703173 www.bupa.co.uk BUPA Care Homes (CFCHomes) Limited Mrs Valerie Anne Bacon Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Shelton Lock Nursing Home DS0000002147.V291525.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 40 places for OP with general health needs aged 65 years and over 20 residential elderley people Variation to admit one (named) service user under the age of 65 years in the category of PD. 1st December 2005 Date of last inspection Brief Description of the Service: Shelton Lock is registered for 40 older people of both genders with nursing and personal care needs. The Home is located in a residential area of Derby it is a purpose built two-storey building, set back off the road. Shelton Lock has double and single en-suite bedrooms. A lift, ramps and other aids are in place. It has a number of areas for sitting and receiving visitors, and a large dining room. Sufficient numbers of bathing facilities are provided. A commercial type kitchen and laundry serve the Home. The Home is surrounded by secure landscaped gardens that are well maintained. There is car parking available. The services available include 24 hour staffed care, personal laundry, and 3 meals per day, a range of activities and social events are available if the residents wish to engage in them. Shelton Lock Nursing Home DS0000002147.V291525.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit that took place at the home over a five and a half hour period time was also spent in preparation for the visit, looking at previous reports and other documents. During the inspection apart from examining a number of the homes records, resident and staff files, time was spent looking around the building speaking to residents, relatives, the manager and staff. The inspector focussed on the requirements made in the last inspection report dated 09/08/05 and the standards not assessed during the last inspection. What the service does well: What has improved since the last inspection? Channels of communication between staff and the manager have improved greatly. There are regular meetings held with staff, residents and relatives all are recorded and displayed. Shelton Lock Nursing Home DS0000002147.V291525.R01.S.doc Version 5.1 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. Shelton Lock Nursing Home DS0000002147.V291525.R01.S.doc Version 5.1 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 Shelton Lock Nursing Home DS0000002147.V291525.R01.S.doc Version 5.1 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): 3.4.5. An individual needs assessment for each potential resident is completed prior to being offered permanent residency in the home. Information is given to potential residents and their relatives to enable them to make an informed choice about the home and the services they offer. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service EVIDENCE: Three individual case files were assessed during this inspection for the purpose of case tracking two of the residents files examined indicated that a full needs assessment had been completed and the manager demonstrated that the third resident had been admitted at the weekend for two weeks respite care and the documentation was in the process of being put into the residents personal file. The needs assessments were detailed and informative. All permanent and potential residents are given a Service Users Guide, which was examined and found to be satisfactory. Shelton Lock Nursing Home DS0000002147.V291525.R01.S.doc Version 5.1 Page 9 Residents and relatives are given the opportunity to visit the home and trial periods of stay are offered to potential residents prior to being offered a permanent place. Shelton Lock Nursing Home DS0000002147.V291525.R01.S.doc Version 5.1 Page 10 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): 7.8.10.11. Satisfactory Care Plans are in place and residents can access a wide range of health services when needed. Resident’s privacy and dignity is respected at all times. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service EVIDENCE: All three of the residents files contained detailed Care Plans from care managers and nursing assessments of care when transferred from a hospital. Risk assessments had been completed these included nutritional scoring, water low, falls and moving and handling. The risk assessments completed were reviewed and updated as and when changes in the resident’s situation were noted. Reviews are now taking place monthly and a record of reviews are held on each resident’s file. The home has a policy in place for respecting residents privacy and dignity during the inspection staff were noted knocking at residents doors before entering locks are fitted to residents doors and residents are offered a key Shelton Lock Nursing Home DS0000002147.V291525.R01.S.doc Version 5.1 Page 11 where appropriate to do so. All residents are asked for their chosen term of address and this is recorded in their file. Staff are available for assisting residents with their food and staff were observed responding to residents needs in a sensitive and caring manner as promptly as possible, although one resident was noted to be asking to go to the toilet after lunch and no staff were available at that time to assist. The home has a policy in place for the acre of residents who are dying, residents funeral religious requests are noted as part of the assessment process. Residents have a wide range of health services available which includes oral optical and hearing tests as and when needed each resident has a general practitioner allocated to them, district nurses visit as appropriate and the general practitioner can refer residents for occupational and speech therapy if needed. Chiropody is available from both private and National Health Services. Shelton Lock Nursing Home DS0000002147.V291525.R01.S.doc Version 5.1 Page 12 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): 13.15. Visitors are made welcome to the home and residents are encouraged to have visitors. The food provided is presented well and nutritionally well balanced. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service EVIDENCE: The home has an ‘open door’ policy in place for visitors the visitors book was examined and there are a good number of regular visitors to the home. During the inspection there were a number of visitors available to talk to, five were spoken to on the day of the inspection all stated that they were made welcome in the home at any time two visitor came on a regular lunch time visit and assisted their relatives with their lunch. All the resident’s spoken to stated that they received visitors albeit not as often as they would like. The home has now employed another new chef and residents spoke of the food as ‘much improved’ the food provided on the day of the inspection was well presented each resident is served individually and according to their needs. Residents’ likes and dislike are recorded and passed to the kitchen. The cook when asked about diabetic foods did not demonstrate a good knowledge of the needs of diabetics. The menus were examined and found to be satisfactory. The dining area was warm clean and light tables were laid with clean cloths and flowers were on each table. The meal time observed was generally relaxed although staff had to work very hard to meet the needs of the residents. Shelton Lock Nursing Home DS0000002147.V291525.R01.S.doc Version 5.1 Page 13 Residents spoken to spoke highly of the food provided and one commented on how nice it was to have a ‘hot tea’ alternative to sandwiches. Shelton Lock Nursing Home DS0000002147.V291525.R01.S.doc Version 5.1 Page 14 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. Complaints are dealt with appropriately and promptly most of the staff have received Adult Protection training and the home had in place a robust recruitment policy. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service EVIDENCE: The home has a record of all complaints made to the home these were examined there had been six complaints made since the last inspection dated 09/08/05 five of the complaints had been dealt with and a resolution reached and one was ongoing at the time of the inspection. All the complaints had been dealt with promptly and in accordance with the homes own policy and procedures. Although a number of staff have had training in the Protection of Vulnerable adults there were a small number who had not attended this training and the manager stated that a new date for training was to be arranged for the remaining staff. Three staff files were examined and the appropriate procedures had been followed all the documents identified in Schedule 2 were in place, Criminal Record Bureau, Protection of Vulnerable Adults and medical checks had been completed, two references and a photograph of the member of staff were held on file. Shelton Lock Nursing Home DS0000002147.V291525.R01.S.doc Version 5.1 Page 15 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): 21.24. The home is generally well maintained internally and externally, bathrooms are cluttered and one bathroom was unusable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service EVIDENCE: Eight residents bedrooms were assessed all were found to meet the requirements as indicated in Standard 24 all the rooms assessed were personalised with items residents had brought with them to the home. There was some minor decoration needed particularly with skirting boards where wheelchairs had damaged the paintwork. Two bathrooms were found to be cluttered with hoist and various pieces of equipment one bathroom was not usable as new beds had been stacked in the bathroom in addition the lock had been removed and this represented a potential health and safety risk to any resident who may have wandered into the room. The manager stated that this would be addressed before she went of duty. Shelton Lock Nursing Home DS0000002147.V291525.R01.S.doc Version 5.1 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 Staffing levels and deployment of staff has improved. However staff achieving National Vocational Qualification Training is still very low. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service EVIDENCE: The staff rotas were examined and found to be satisfactory staffing levels and the deployment of staff has been reviewed and this has improved the service to residents considerably, residents are now got up at a more reasonable hour in the morning and in time to have their breakfast and medication. There was some evidence that more staff were needed at meal times as some residents waited a while to be moved from the table and if relatives did not come in to assist their relatives at lunch time staff would be stretched further and this could cause problems for resident who need to be assisted with their food. Staff have received the mandatory training including Induction, a training matrix is in place and was examined the indication was that whilst there were only five care staff had achieved National Vocational Qualification Training level 2 there were a further five staff in the process of taking their National Vocational Qualification Training and three further staff to be enrolled this year. A number of staff have attended courses for Dementia and Infection Control. Staff spoken to during the inspection confirmed that they now had good training opportunities offered to them and were enabled to attend when possible. Residents spoken to spoke highly of the staff care although one did say that one or two of the staff tended to rush them a little. Shelton Lock Nursing Home DS0000002147.V291525.R01.S.doc Version 5.1 Page 17 It was noted that a number of accidents had occurred as a result of being moved by staff on one such occasion the member of staff had moved the resident into a wheelchair on their own this had led to the resident falling to the floor and sustaining an injury. Shelton Lock Nursing Home DS0000002147.V291525.R01.S.doc Version 5.1 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): 31.32.37. The manager and staff relationship is now improving communication channel are now in place to aid staff, residents and the manager to communicate more effectively. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service EVIDENCE: A number of staff were interviewed during the inspection and whilst there were still some negatives expressed the majority of the comments were positive and staff felt that their relationship with the manager had improved. Both staff and the manager confirmed that there had been a number of staff meetings and team building session had taken place since the last inspection dated 09/08/05 and this had helped to improve the situation. It was observed during the inspection that there was more two-way communication taking place. Shelton Lock Nursing Home DS0000002147.V291525.R01.S.doc Version 5.1 Page 19 The manager has a number of years experience in this field of work and is due to complete her National Vocational Qualification Training level 4 at the end of April. The home holds regular residents and staff meeting. Two notice boards are now used to inform staff of changes in policies and procedures or important dates. All the meetings held are recorded and copies are displayed on the notice board. There is a resident/relative meeting held three monthly this enables residents to take up any issues of concern and suggestions for change. A number of the homes records were examined including menus, staff rotas, accidents, complaints, Care plans and staff files all were found to be satisfactory. Shelton Lock Nursing Home DS0000002147.V291525.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 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 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x 2 x x x x x STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x x x x x Shelton Lock Nursing Home DS0000002147.V291525.R01.S.doc Version 5.1 Page 21 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP37 OP21 OP15 Good Practice Recommendations All staff must receive training in moving and handling and The Protection of Vulnerable Adults. Bathrooms should be free from clutter and safe for residents use. Door locks should be fitted to ensure residents privacy. kitchen staff should receive training with regard to special diets including diabetes. Shelton Lock Nursing Home DS0000002147.V291525.R01.S.doc Version 5.1 Page 22 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 Shelton Lock Nursing Home DS0000002147.V291525.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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