Inspection on 15/11/05 for Shepley House

This inspection was carried out on 15th November 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.

Other inspections for this house

Shepley House 18/10/06

Shepley House 16/05/05

Shepley House 10/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Shepley House Eyam Road Hazel Grove Stockport Cheshire SK7 6HP Lead Inspector Sylvia Brown Unannounced Inspection 15th November 2005 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 Shepley House DS0000008588.V263563.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 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. Shepley House DS0000008588.V263563.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Shepley House Address Eyam Road Hazel Grove Stockport Cheshire SK7 6HP 01625 874711 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) Borough Care Limited Mrs. Lesley Ridgway Care Home 40 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (40) of places Shepley House DS0000008588.V263563.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 40 OP and up to 4 DE(E). Date of last inspection 16th May 2005 Brief Description of the Service: Shepley House is a large, purpose built home situated in a quiet residential area in Hazel Grove. The home can accommodate up to 40 older people, all of whom have single bedrooms. The home provides day-care facilities and a luncheon club is also run on a Sunday. There are various communal lounges and dining rooms on both floors. Facilities are available for visitors to make their own drinks and snacks when visiting. There are gardens to the rear of the home, offering residents outdoor seating areas in fine weather. The home is located on the outskirts of Stockport. Shepley House is one of 12 homes owned by Borough Care Limited. The home is equipped with aids and adaptations and there is a lift which serves both floors, enabling residents within diminished mobility to move around the home as independently as possible. Shepley House DS0000008588.V263563.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of Shepley House was unannounced, commencing at 11am. Time was spent with residents, observing day to day routines and staff care practices on the upper floor. The registered manager was on the premises and made herself available throughout the inspection, providing information on the home’s progress in meeting requirements and recommendations made at the previous inspection and provided information to enable an up to date evaluation on current practice at the home. Residents and relatives were provided with comment cards during the inspection. Three were returned by residents and five by relatives prior to the end of the inspection. Comments received are detailed within the report. What the service does well: What has improved since the last inspection? There have been no significant developments since the last inspection, with the home continuing to provide a consistently good service that is well received by residents and their relatives. Shepley House DS0000008588.V263563.R01.S.doc Version 5.0 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. Shepley House DS0000008588.V263563.R01.S.doc Version 5.0 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 Shepley House DS0000008588.V263563.R01.S.doc Version 5.0 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): 1, 2, 3 & 5 Standard 6 not applicable. Prospective residents have their needs assessed and receive information about the home prior to being accommodated, contracts of residency are issued at admission. EVIDENCE: Evaluation of residents’ files confirmed that Shepley House continues to provide prospective residents with information about the home and the services on offer, prior to them making any decisions about their future. Residents are able to visit the home prior to being accommodated to evaluate the services and see the day-to-day living routines and accommodation on offer. Written records by families confirm their findings at the time of visiting which were all positive. Shepley House DS0000008588.V263563.R01.S.doc Version 5.0 Page 9 Placing authorities provided assessments of residents’ need to the home. In addition, the registered manager continues to meet with the prospective residents in their own homes or current placement to undertake an up to date assessment of their individual needs and discuss their preferences for care support. Placing authorities also provide service agreements and contracts at the point of admission, upon completing of the six week probationary period and after review residents are issued with the home’s terms and conditions of residency which are agreed to and signed by the resident and/or their representatives. Shepley House DS0000008588.V263563.R01.S.doc Version 5.0 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, 9 & 10 Residents have their care needs met and are supported to maintain, as far as possible, good health. EVIDENCE: All residents have written care plans which are maintained in the residents’ individual rooms, enabling them to read what is recorded. The care plans are made up from different records which include general assessments and risk assessments. Taking the compilation of records together, adequate details were evident regarding the care needs of residents and how they should be met. Visiting professionals record their findings and detail treatments provided. Residents receive dental, optical and hearing tests on an annual basis and when required. Chiropody treatments are routinely provided. Shepley House DS0000008588.V263563.R01.S.doc Version 5.0 Page 11 Without exception all residents stated they were well cared for and that they received the support they required. Medication records were, in the main, well maintained, however handwritten records for residents on short stay were abbreviated rather than contain all the prescribed administration details. Shepley House DS0000008588.V263563.R01.S.doc Version 5.0 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): 12, 13, 14 & 15 Residents are satisfied with their lifestyles and are able to make their own decisions and choices. EVIDENCE: The home has an appointed activities co-ordinator, who, after receiving training and support from the company, plans and encourages staff to undertake a variety of activities with residents. Residents informed the inspector of the recent activities undertaken and of their enjoyment. Both comment cards from residents stated their satisfaction with the amount of activities provided. On the day of the inspection some residents were observed being encouraged to help staff with arranging flowers around the unit. Residents stated they are able to make their own decisions regarding rising and retiring and where they spend their day, some preferring their own rooms whilst others enjoy mixing within the communal parts of the home. Shepley House DS0000008588.V263563.R01.S.doc Version 5.0 Page 13 Throughout the inspection residents were observed receiving visitors. The home provides a small visitors kitchen which can be used by them or residents to make drinks and light snacks. All five comment cards from visitors stated they were kept appropriately informed regarding their respective relative’s care. One relative stated that “we as relatives are very happy with the care provided. The home is very well run and we have no reason to complain”. Another relative stated “we always find the staff helpful and dedicated to the care of the ladies”. One mealtime was observed, residents stated the meal served was hot, tasty and enjoyable. Resident meetings have identified that meals and menus require some attention to meet with residents’ requirements. Following the completion of quality assurance questionnaires regarding meals and food served, the registered manager has commenced reviewing food options and developing menus with the residents to ensure they receive and have on offer their favoured food. Residents made comment about the length of time they were sat at the dining table before food was served. One resident felt that staff were overworked at this time and would benefit from another person assisting. A recommendation has been made to review all mealtime routines. Shepley House DS0000008588.V263563.R01.S.doc Version 5.0 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 Residents are protected from abuse and are aware of the home’s complaints procedure. EVIDENCE: Residents are consulted on the standard of service provision. Comment cards identified that they were aware of the complaints procedure and felt able to tell the manager of any dissatisfactions they had. One complaint has been received since the previous inspection, records detailed the nature of the complaint and the action taken to find a positive resolution. Staff receive adult protection training and are informed of their responsibility to report any suspicions of abuse and poor practice. All residents confirmed they felt safe and protected and should staff act incorrectly, they stated they would inform the registered manager. Shepley House DS0000008588.V263563.R01.S.doc Version 5.0 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): 19, 20, 21, 22, 23, 24, 25 & 26 Residents live in a well maintained, cared for and comfortable environment. EVIDENCE: Shepley House continues to be a well maintained home; communal areas are bright and cheery with comfortable safe seating. The home was clean and tidy with all areas free from hazards and obstructions. Residents’ individual rooms were also clean and well maintained. Rooms observed were found to be personalised to the individuals’ tastes and preferences. Residents are encouraged to bring in small items of furniture and personal items from their own home, all of which are recorded for safe keeping. Aids and adaptations were evident to support residents’ care needs, including adjustable beds, hoists, foot stools and pressure relief equipment. Shepley House DS0000008588.V263563.R01.S.doc Version 5.0 Page 16 One carpet, in the upper dining room, was observed to be threadbare where the carpet has been joined. Though not currently a hazard to residents, it requires attention to prevent future risks. Residents informed the inspector that dining room chairs were uncomfortable when seated for long periods and, though cushions provided some relief, the general consensus was that they would prefer new more suitable chairs. Bathing and toileting facilities are in appropriate number, clean and adapted to meet the needs of those who require additional support. Shepley House DS0000008588.V263563.R01.S.doc Version 5.0 Page 17 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 The home has effective recruitment and training procedures in place. EVIDENCE: On the day of the inspection staffing levels were appropriate to meet the needs of residents. Evaluation of the rota identified that staffing levels were adjusted to meet peak periods throughout the day and that staff were deployed appropriately. Inspection of staff files confirmed that the home continued to have effective recruitment procedures in place and that statutory checks were undertaken prior to employment being affirmed to safeguard residents. Records demonstrated that induction and foundation training were in place, and that continuing training programme and supervision ensured staff practice was monitored and that staff were competent in their duties. One resident’s comment card stated that she was ‘pleased with the care and attention she received and that staff are wonderful’. Shepley House DS0000008588.V263563.R01.S.doc Version 5.0 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, 34, 35, 36, 37 & 38 Shepley House is a well managed and run home. EVIDENCE: Since the last inspection, the registered manager has returned from long term sick leave. Throughout the inspection, she was knowledgeable regarding the care needs of residents and able to provide up to date information regarding developments in practice and future plans to further improve standards within the home. Relatives appeared to have positive relationships with staff and the registered manager. One comment card stated ‘anything I need to know, I just ask the manager’, indicating that she makes herself available to visitors and is able to answer any queries they may have. Shepley House DS0000008588.V263563.R01.S.doc Version 5.0 Page 19 Quality assurance procedures have commenced regarding some service provision. Accounting systems are in place for small balances held on behalf of residents with receipts for all expenditures being retained. Routines are in place to ensure health and safety checks are completed and, as far as possible, ensure residents safety. Accidents are recorded and evaluated and fire safety procedures are carried out as required. Regulation 26 visits are conducted each month by a company representative who evaluates practice, records and the environment; a report of each visit is supplied to the CSCI. In their completed comment card, one relative stated, ‘the standard of care is very high and I could not be more pleased that mum is being looked after so well’. Shepley House DS0000008588.V263563.R01.S.doc Version 5.0 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 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 2 3 3 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 3 3 3 3 3 Shepley House DS0000008588.V263563.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? NO 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 OP9 Regulation 13(2) Requirement The registered person should ensure handwritten medication instructions on the medication administration record detail administration and prescribed. Cease abbreviating administration information. Timescale for action 16/11/05 Shepley House DS0000008588.V263563.R01.S.doc Version 5.0 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP15 Good Practice Recommendations The registered person should review all mealtime routines, ensuring residents are not sat at tables for long periods of time waiting for meals to be served and that there are sufficient staff to provide timely and efficient support. The registered person should make good the dining room carpet on the first floor where it is evident that joins are becoming threadbare. The registered person should after consultation with residents provide comfortable dining chairs. 2 3 OP24 OP24 Shepley House DS0000008588.V263563.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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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