Inspection on 16/05/05 for Shepley House

This inspection was carried out on 16th May 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 15/11/05

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 SK7 6HP Lead Inspector Sylvia Brown Announced 16 May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 F54 F04 shepley house A s8588 v219859 160505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Shepley House Address Eyam Road, Hazel Grove, Stockport, SK7 6HP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01625-874711 01625-876410 Borough Care Limited Mrs L Ridgway Care Home CRH 40 Category(ies) of Dementia - over 65 years of age (4) registration, with number Old age, not falling within any other category of places (40) Shepley House F54 F04 shepley house A s8588 v219859 160505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: - Date of last inspection 6 January 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 also provides daycare facilities and a luncheon club is also run on a Sunday. The home consists of 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 homes location on the outskirts of Stockport, does restrict access to local shops, as the nearest bus service is a ten minute walk away. 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 F54 F04 shepley house A s8588 v219859 160505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of Shepley House was conducted over one day, starting at 8am with a total of 7.5 hours on the premises. The home had prepared well for the inspection and completed a pre-inspection questionnaire despite the manager not being available for the inspection due to illness. Residents, relatives and medical professionals were provided with comment cards prior to the inspection. One was returned by a resident, six from relatives and two returned from medical practitioners. During the course of the inspection the inspector spent time with residents as they went about their daily routines and shared two mealtimes with them. The inspector spoke at length with four residents and one family member. Comments made and received are included within the report. What the service does well: What has improved since the last inspection? This could not be fully assessed, as this was the inspector’s first visit to the home. Two requirements were made at the previous inspection relating to policies and procedures, and the implementation of NVQ training for staff. Both of the requirements have been achieved. Shepley House F54 F04 shepley house A s8588 v219859 160505 stage 4.doc Version 1.30 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 F54 F04 shepley house A s8588 v219859 160505 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Shepley House F54 F04 shepley house A s8588 v219859 160505 stage 4.doc Version 1.30 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 standard(s) 1, 2, 3,4 & 5 Standard 6 is not applicable to Shepley House. Residents are provided with sufficient information to enable them to make informed decisions about their accommodation prior to and during their stay. EVIDENCE: Residents stated that they were able to visit the home and spend time evaluating the services and view the accommodation prior to making any decisions about their placement. The home’s statement of purpose and service user guide are provided to all residents. Inspection of care files confirmed that residents are also provided with contracts and terms and conditions of residency. Shepley House F54 F04 shepley house A s8588 v219859 160505 stage 4.doc Version 1.30 Page 9 Inspection of residents’ files also confirmed that assessments of residents’ needs are completed prior to admission. The assessments are initially reviewed within six weeks of the placement commencing and then periodically amended as the needs of residents increase or decrease. One resident spoken to did not understand why they were still living at the home. On speaking with the deputy manager it became apparent that the resident has made good progress towards living semi-independently and that 24 hour care may not necessarily be required. Shepley House F54 F04 shepley house A s8588 v219859 160505 stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 & 10 Support is provided to maintain residents’ good health. Residents received their medication appropriately and in private, where required. Care plans did not detail all the residents’ care need. EVIDENCE: All residents had written care plans in place. Details confirmed that residents received health care support from, GP’s, District Nurses, Chiropodist and Dentist. Comment cards received from medical support services stated that the home communicated well with them and that they were able to attend to the residents’ care in private. The inspector observed one particular resident as having specific behavioural issues. Communication records also confirmed that the resident had disrupted night time routines which require specific management, however this was not identified within the resident’s care plan. Another resident had specific behaviour due to the effects of a stroke which were not recorded within the care plan. Shepley House F54 F04 shepley house A s8588 v219859 160505 stage 4.doc Version 1.30 Page 11 Observations of medication administration identified that it was completed sensitively and to the required standard. Medication records were maintained appropriately. One resident’s comment cared stated “its a beautiful place to have my respite care, the staff are very helpful and kind, nothing is too much trouble”. All relatives’ comment cards stated their satisfaction with the care and support provided at the home. One relative stated he felt the care and support provided were excellent. Shepley House F54 F04 shepley house A s8588 v219859 160505 stage 4.doc Version 1.30 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 standard(s) 12, 13, 14 & 15 Residents’ independence is promoted and they are encouraged and supported to continue to have control over their own lives. Residents received a well balanced diet with menus offering choice and variety. EVIDENCE: Residents were observed rising as they wished and receiving breakfast at differing times. One resident was observed attending a therapy group within the community, two others informed the inspector that they attended outside activities and went to bingo. Comments regarding the home’s own activity programme varied, some residents stated it was enough, whilst others felt there could be more. Some residents informed the inspector that they attended the home’s day care and enjoyed meeting others from outside of the home. Relatives’ comment cards stated they were made to feel welcome and that visiting was unrestricted. They also confirmed that where residents had reduced capacity, they were consulted about their care and able to contribute to the decision making process. Shepley House F54 F04 shepley house A s8588 v219859 160505 stage 4.doc Version 1.30 Page 13 Residents had differing opinions regarding food served. At breakfast residents spoke of their pleasure at having various choices, including hot food, whilst others at lunch stated main meals were sometimes bland. Shepley House F54 F04 shepley house A s8588 v219859 160505 stage 4.doc Version 1.30 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 standard(s) 16 & 18 Residents’ safety is protected and complaints raised are taken seriously, however information about making complaints was not consistently provided. EVIDENCE: The home has written adult protection policies and procedures in place. Staff have been trained in adult protection matters and are aware of their responsibility to report all suspicions or allegations of abuse. There have been no allegations of abuse reported at the home. The home has a written complaints procedure in place that is made available to residents and visitors to the home. The pre-inspection questionnaire identified that since the last announced inspection two complaints had been received by the home. Of the six comment cards returned, two relatives stated that they had made a complaint. Two others stated they were not aware of or had received any information about the home’s complaints procedure. Shepley House F54 F04 shepley house A s8588 v219859 160505 stage 4.doc Version 1.30 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 standard(s) 19, 24 & 26 Residents live in a safe clean environment. EVIDENCE: The home was clean and tidy on the day of the inspection, there were no unpleasant odours. One resident stated she had been encouraged to bring in small items of furniture from her own home when admitted . Residents spoken to spoke positively of the home and of the comfort of their surroundings. Shepley House F54 F04 shepley house A s8588 v219859 160505 stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 Residents’ needs are met and safeguarded by staff who are recruited, selected and trained appropriately. EVIDENCE: Inspection of staff files and training records identified that staff are recruited and selected appropriately and, for the protection of residents, statutory checks are made and received prior to new staff commencing duty. Shepley House has taken its responsibility to provide residents with well trained and competent staff seriously. Training records confirmed that staff are trained through the home’s internal training programme and complete induction processes. Of the 21 care staff, ten have completed NVQ training at level 2, five are currently undertaking the training with a further four nominated for training in the future. Four of the senior team have completed NVQ training at level 3, which enhanced the care provided to residents. Comment cards from medical professionals stated that staff demonstrated a clear understanding of the residents’ care needs. Staff were observed transferring residents in wheel chairs without the use of footrests. Such practice places residents at an increased risk of accident and does not meet safety standards. Shepley House F54 F04 shepley house A s8588 v219859 160505 stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36, 37 & 38 Shepley House is a well run and managed home. EVIDENCE: In the absence of the registered manager the deputy manager has provided leadership and continued to maintain appropriate standards. Throughout the inspection she was knowledgeable about residents’ individual care needs, staff, policies and procedures and of her statutory responsibilities whilst running the home. She has completed NVQ training at level 3 and is competent to manage the home in the absence of the registered manager. Shepley House F54 F04 shepley house A s8588 v219859 160505 stage 4.doc Version 1.30 Page 18 The home does not take responsibility for managing residents’ finances, however accounting systems were in place for the auditing of small balances held on behalf of residents. Some residents contribute to the home’s amenity/ social fund. Records relating to the amenities funds were inspected; the balance was considerable. Residents’ opinions should be sought on how the funds should be spent. The home has a full set of policies and procedures in place. Health and safety records were inspected and found to be in order. Fire safety records required some amending to ensure persons completing fire safety training could be identified. Shepley House F54 F04 shepley house A s8588 v219859 160505 stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 1 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 3 3 3 2 3 3 3 2 Shepley House F54 F04 shepley house A s8588 v219859 160505 stage 4.doc Version 1.30 Page 20 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 OP6 Regulation 12 & 14 Requirement The registered person must ensure that residents who request to live independently are reassessed and are given where safe to do so the opportunity to live within the community. The registered person must ensure that care plans detail all the needs of residents, including behaviour support and or management. The registered person must ensure that safe moving and handling techniques are carried out at all times. The registered person must ensure that all residents and relatives are informed of and receive a copy of the homes complaint procedure. Timescale for action 01/07/05 2. OP7 17 & Schedule 3 13 (5) 15/06/05 3. OP28 17/05/05 4. OP16 22 15/06/05 5. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations F54 F04 shepley house A s8588 v219859 160505 stage 4.doc Version 1.30 Page 21 Shepley House 1. OP5 The registered person should consult with residents regarding their opinions on meals served, where and if identified make changes to improve the variety, and quality of food served. The registered person should consult with residents regarding the how the balance of their amenities fund should be spent. The registered person should ensure that records of staff completing practical fire drill training can be identified 2. 3. 4. 5. OP35 OP38 Shepley House F54 F04 shepley house A s8588 v219859 160505 stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 2nd Floor Heritage Wharf Portland Place Ashton under Lyne, 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. Extracts may not be used or reproduced without the express permission of CSCI Shepley House F54 F04 shepley house A s8588 v219859 160505 stage 4.doc Version 1.30 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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