Inspection on 18/10/06 for Shepley House

This inspection was carried out on 18th October 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

Shepley House 15/11/05

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 Kath Oldham Unannounced Inspection 18th October 2006 08:50 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.V315477.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Shepley House DS0000008588.V315477.R01.S.doc Version 5.2 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.V315477.R01.S.doc Version 5.2 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 15th November 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 have single bedrooms. The home provides day-care facilities on four days each week and a luncheon club is run on 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 the 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 with diminished mobility to move around the home as independently as possible. The home has a statement of purpose and service user guide which were reported to be given to prospective service users or their families when they visit the home to look round. The fees for staying at the home were reported to be between £332 and £390 per week. Shepley House DS0000008588.V315477.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of Shepley House was unannounced and commenced at 8:50am. The inspection focused on past requirements and recommendations to see how the home had developed; to examine records and to spend time in conversation with service users. During the inspection time was spent in conversation with the deputy, care supervisor and manager and the examination of records, which must be kept in line with regulations. Comment cards were left at the home for distribution to service users and their friends, relatives and visitors. The comments received are included in this report. Staff were also left comment cards to comment on the service provided. Their comments are included in this report. The case files of three service users were looked at in detail, looking at their experiences in the home from their time of admission to the present day. Breakfast was taken at the home with service users and a partial inspection of the premises was undertaken. The inspector spoke with service users and several members of staff who were on duty. The deputy manager was on duty during the morning and the manager was on duty in the afternoon. Verbal feedback was given to the manager on conclusion of the inspection. What the service does well: Service users continue to be at the forefront of the service provided at the home. Some service users have been at the home for a number of years and are happy with their lives. The home has a happy atmosphere and a number of service users actively contributed to the inspection process through conversation and the completion of comment cards. Shepley House DS0000008588.V315477.R01.S.doc Version 5.2 Page 6 All comment cards received were positive about the care service users receive and the staff team. Visitors and relatives’ comment cards made reference to the home being happy and the staff being welcoming. Several service users told the inspector that they liked living at the home and that they felt well cared for. Service users appeared to be well cared for and were supported by a trained and competent staff group. The home is comfortably furnished and provides an environment that helps to maintain the independence of service users for as long as possible. Staff turnover is low and they are supported through the supervision process. Staff training is given a high profile, and a lot of the staff have obtained NVQ qualifications. Service users said, “Staff are wonderful.” They also discussed activities the home provides and gave examples of trips and meals out. Some service users said they preferred not to be involved with social activities and spend more time in their room for peace and quiet, and felt free to make choices in their daily lives. What has improved since the last inspection? A number of bedrooms have been redecorated and the lounge has also benefited from being wallpapered. The downstairs lounge was scheduled to be wallpapered in the week of the inspection. Handwritten medication has been transcribed, as per the instructions from the GP, with no abbreviations of the administration information. The manager said staff practice has been amended so service users are not waiting for long periods of time at the dining table before meals are served. Relatives and service users were positive about their experiences at the home and re-stated that their cared for relative received everything they needed and they were secure in the fact when they went home their cared for service user was secure and safe. Shepley House DS0000008588.V315477.R01.S.doc Version 5.2 Page 7 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.V315477.R01.S.doc Version 5.2 Page 8 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.V315477.R01.S.doc Version 5.2 Page 9 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 (Standard 6 not applicable) Quality in this outcome area is good. Information is provided to service users to allow them to make a judgement about whether they wish to reside at the home and the home assesses prospective service users to ensure they can meet their needs. This judgement has been made using available evidence, including a visit to this service EVIDENCE: Two service users indicated that they had received a contract and they received enough information about the home before they moved in so they could decide if it was the right place for them. Service users wanting to live at Shepley House are assessed to identify whether their needs can be met by the home. Examination of a sample of the care files identified an assessment in place. Shepley House DS0000008588.V315477.R01.S.doc Version 5.2 Page 10 Service users are able to visit the home before making a decision whether they want to live at the home. One service user said she came to the home on a number of occasions before deciding she would like to try it. A review meeting is arranged to see if the service user is settling in and to make any changes to any aspect of the care provided. The inspector met several service users who told her that they were happy with the way in which the home was meeting their needs. Several service users said they felt well cared for. Staff said they familiarised themselves with service users’ care plans. The home operated the key worker system and they felt this assisted their knowledge of specific service users. Care staff demonstrated a good understanding of service users’ care needs. Shepley House DS0000008588.V315477.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. Systems are in place to ensure, as far as possible, service users maintain good health. Care plans need further improvement to reflect this. This judgement has been made using available evidence, including a visit to this service EVIDENCE: Examination of a sample of service user care files identified all had a care plan in place. The detail contained within the care plan about the specifics of the care was not always clear. The daily recordings indicated that care needs had been provided but did not detail what aspects of care had been provided. The manager said she was aware of this and intended doing some work with the staff team to develop their skills in completing a clearer record. Care plans were reviewed and amended to detail the change in service users’ care needs. Shepley House DS0000008588.V315477.R01.S.doc Version 5.2 Page 12 A record is maintained of visits or appointments made to health care professionals, the detail of which can be researched to inform of treatments or plans that are put in place. One service user said they forget things and do not always know the time of day, but they know they have nothing to worry about as the staff will look after them and make sure they are well. Visiting professionals said the home works with them in promoting service users’ healthcare needs. Staff in conversation stated how they promote service users’ privacy and dignity when carrying out personal care and when speaking about personal matters. Staff practice was observed on the inspection and time was taken discreetly by staff when undertaking personal care tasks. Examination of the medication administration records identified them to be completed as prescribed by service users’ GPs. Handwritten medication was not verified by a second member of staff to ensure the details had been copied accurately. This provides an extra safeguard for service users and staff. A photograph was on the service users’ medication records to assist in identification. Specimen signatures are in the records as a means of identifying the staff with responsibility of administering medication. Service users were seen receiving their medication, which was undertaken sensitively with staff taking into account service users’ abilities and understanding. Service users said they received their medication routinely and staff explained what particular tablets were for if they couldn’t remember. A service user was aware of what medication they were prescribed and said they received it as directed by their doctor. Shepley House DS0000008588.V315477.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 Quality in this outcome area is good. Service users have a flexible lifestyle in the home and maintain contact with their families and friends. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The day-to-day routine of the home was relaxed and informal. One service user said they do what they want, get up and go to bed when they are ready and see who they want and go out if they feel like it. The majority of service users said they were happy with these arrangements. Relatives said there were no restrictions on visiting and they visit when it suits them and their cared for service user. They spend time in the lounge or in the service user’s bedroom. Service users said they have their own routines and the home’s routines, which suit them. There are organised activities within the home, with entertainers visiting. Some service users said there wasn’t enough to do and there should be more visits out for a couple of hours and more regular exercise, as they spend a lot of time sitting. Shepley House DS0000008588.V315477.R01.S.doc Version 5.2 Page 14 Visitors were welcome to the home and the home maintained contact with the local community, i.e., church visits. Service users were able to see visitors in private. One relative said they are always made to feel welcome by the staff and by other service users who they have got to know from their visits. Menus are in place on the tables, which act as a reminder of the meal to be served. The menus on the tables did not reflect the meals being served on the inspection, which caused some confusion as service users were expecting something which wasn’t served. One service user said they didn’t like the meals and much preferred other meals, which weren’t on the menu. The manager said she was aware of these comments and had arranged to meet with the service user and their relative to try to sort this out. Other service users said the meals were good and there was always plenty to eat. The menus did not include an alternative to the main meal of the day. The cook said service users could have something different from the menu. The meals at the inspection were attractively presented and time was taken by staff in supporting and encouraging some service users to eat their meal. Shepley House DS0000008588.V315477.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. A complaints procedure known to service users was in place. Systems and routines are in place to protect and safeguard service users from abuse. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Service users said if they had problems they would speak to the manager or specific staff. A complaints procedure is in place and describes the steps that will be undertaken to investigate any complaints or comments. Staff said they had every confidence that service users and their relatives would approach any member of the staff team with any comments or complaints. Service user meetings were described as an opportunity to talk things over and put forward any ideas for change. Most service users said they had no complaints and were happy with the care they receive. Examination of the complaints record did not detail any comments or complaints for some considerable time. The manager described comments that have been made by service users, none of which were recorded. Shepley House DS0000008588.V315477.R01.S.doc Version 5.2 Page 16 The comments and complaints from service users and their representatives is an integral part of a home’s quality assurance and should assist in the development of the home. The recording of comments and complaints needs to be further developed. Adult protection training has taken place to inform staff what constitutes abuse and to ensure they are familiar with the actions to be taken if they suspect abuse. A whistle blowing procedure is in place and staff were aware of what they would do if any practice or routine is not of an acceptable standard. Shepley House DS0000008588.V315477.R01.S.doc Version 5.2 Page 17 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 & 26 Quality in this outcome area is good. Shepley House is a safe and generally well-maintained home. The home provides a comfortable environment and is clean and tidy. Service users’ bedrooms are personalised and comfortable. This judgement has been made using available evidence, including a visit to this service EVIDENCE: Examination of the records identified safety checks undertaken to the equipment in the home. Regular service contracts were in place, in addition to the maintenance man coming to the home to do routine jobs. The home was clean and tidy. Service users have ample access to bathing and toileting areas, which were maintained to a good standard. Shepley House DS0000008588.V315477.R01.S.doc Version 5.2 Page 18 Service users have access to the lounges and dining rooms. The decorators were at the home redecorating one of the lounges. Staff supported service users whilst this work was being undertaken, trying to ensure they were least disrupted. Service users’ bedrooms had everything in them to make them feel comfortable and at home in their surroundings. A number of service users have brought into the home small items of furniture, ornaments and pictures to make the room their own. The bedrooms were clean. There had been no physical changes to the home environment since the last inspection. Standards of hygiene and cleanliness throughout the home were good at the time of the site visit. The home provided comfortable accommodation and was free from any unpleasant odours. One relative said the home was always spotless and there were never any odours. Shepley House DS0000008588.V315477.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. There was an appropriate number of staff who were trained and competent to meet the assessed needs of service users. The procedures for the recruitment of staff safeguarded service users. This judgement has been made using available evidence, including a visit to this service EVIDENCE: Staff spoken to said that staffing levels were satisfactory and there was little use of agency staff. The agency, when contacted, is asked to provide staff who are known to the home. Service users said that staff they knew provided care to them and knew what they needed. In addition, there is also a care supervisor on duty throughout the day. Staff duty rotas showed that there was sufficient staff on duty to meet the needs of service users. Staff have received mandatory training in topics such as moving and handling, food hygiene and fire procedures. A system is in place to record the training received by staff which ensures that health and safety updates are delivered at the appropriate time. Shepley House DS0000008588.V315477.R01.S.doc Version 5.2 Page 20 Service users were complimentary about the skills and personalities of the staff at the home. Service users said staff were “kind and considerate” and “would do anything for you”. Service users said they felt safe at the home. Many of the staff have received NVQ training and are able to use their skills to provide the right level of care to service users. Service users said “you only have to ask and staff will provide for you”. Examination of a sample of staff files confirmed that staff recruitment was thorough and robust, including receipt of references, and CRB disclosures. Shepley House DS0000008588.V315477.R01.S.doc Version 5.2 Page 21 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, 33, 35 & 38 Quality in this outcome area is good. The management of the home are approachable and focus on meeting the needs of service users. This judgement has been made using available evidence, including a visit to this service EVIDENCE: The registered manager continues to be committed to the home and ensures that routines are, in the main, around the needs and preferences of residents. The home complied with the requirements of the fire authority. The home maintained records in respect of fire safety at the home. Staff spoken to were aware of what to do in the event of fire and confirmed they had received fire drill training and practice. Shepley House DS0000008588.V315477.R01.S.doc Version 5.2 Page 22 Staff meetings are arranged at the home, notes are made of the meetings, which provide staff with an opportunity to discuss areas of development within the home and to influence practice and routines. Accident records were completed correctly and audited monthly. Service user meetings are arranged and service users contribute to the meeting, sharing their views and opinions. A service user said they didn’t know about the residents meetings and would ask staff when they are. A further service user said they don’t always know what to talk about at the meeting as they are not used to meetings. A selection of records relating to money held by Shepley House on behalf of service users was examined. These presented as being maintained appropriately to protect the interests of service users. Maintenance records viewed were up to date. Shepley House DS0000008588.V315477.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 2 17 X 18 3 3 X X X X X X 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 X 3 X 3 X X 3 Shepley House DS0000008588.V315477.R01.S.doc Version 5.2 Page 24 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. 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 Refer to Standard OP7 Good Practice Recommendations The registered person should develop the recording within the care plans and daily reports, ensuring the content is an accurate reflection of service users’ care needs and how and when these are provided. The registered person should arrange for a second staff member to verify the entry in the medication administration records when these are handwritten. The registered person should make sure that the written menu offers a choice of main meal and that the displayed menu is reflective of the meals to be served. The registered person should further develop the recording of complaints ensuring they are reflective of the comments received and the action taken to remedy the comment or complaint. 2 3 4 OP9 OP15 OP16 Shepley House DS0000008588.V315477.R01.S.doc Version 5.2 Page 25 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. Extracts may not be used or reproduced without the express permission of CSCI Shepley House DS0000008588.V315477.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!