Inspection on 12/12/05 for Shipley Hall Nursing Home

This inspection was carried out on 12th December 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Shipley Hall Nursing Home 13/07/09

Shipley Hall Nursing Home 28/07/08

Shipley Hall Nursing Home 27/04/07

Shipley Hall Nursing Home 27/04/06

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 Shipley Hall Nursing Home The Field Shipley Heanor Derbyshire DE75 7JH Lead Inspector Eileen McHale Unannounced Inspection 12th December 2005 10:00 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 Shipley Hall Nursing Home DS0000065551.V272824.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. Shipley Hall Nursing Home DS0000065551.V272824.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Shipley Hall Nursing Home Address The Field Shipley Heanor Derbyshire DE75 7JH 01773 764906 01773 764906 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) Shipley Hall Limited Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Shipley Hall Nursing Home DS0000065551.V272824.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Responsible Individual must submit a Manager for registration within 3 months of registration. One MD place for the service user named in the notice of proposal letter dated 29 November 2005. 30/6/05 Date of last inspection Brief Description of the Service: Shipley Hall Care Home is set in attractive parkland grounds. There is a pond within the grounds and the gardens attract a variety of wildlife. The home is a converted, turn of the century, tastefully extended building providing facilities for thirty service users. There are five day/quiet rooms, which include a light and airy conservatory overlooking the pleasant garden areas. Accommodation is provided on ground and first floors, with passenger lift and staircase access to the first floor. A stair-lift provides assisted access to one of the first floor bedrooms. There are eighteen single bedrooms and six double bedrooms, all with wash hand basins. No en-suite rooms are provided, but the home has adequate provision of WC and bath/shower facilities throughout, including an assisted bath. Service users are encouraged to personalise their rooms if they wish. All rooms are equipped with a call system. Support services are in place with a choice of General Practitioners, and chiropody, dental, optician and other services arranged as appropriate. A hairdressing service is provided at the home. Shipley Hall Nursing Home DS0000065551.V272824.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days due to other commitments of the responsible person. As a complaint was made about the home, the second day of the inspection began at 7.30 am to observe care arrangement in the morning. The ownership of the home had changed since the last inspection. The new proprietors had begun to implement many changes in the home, which included general refurbishment of the premises, attention to required training and attention to care planning and care practices. Within this process there had been a high rate of staff turnover and complaints about management practices from the original staff group. What the service does well: What has improved since the last inspection? There have been major changes since the last inspection and although these are ongoing, a number of improvements were clearly taking place. At the time of the inspection the following improvements were taking place-Greater care was being taken on the admission of residents with formal arrangements in place for the admission of residents with needs outside the home’s registration category. - Care planning was under review with revised care plans and attention being paid to care practices. - Ongoing attention was being paid to staff training and significant improvements had been made to health and safety training (including moving and handling), training in the management of medication and adult protection training. Shipley Hall Nursing Home DS0000065551.V272824.R01.S.doc Version 5.0 Page 6 -The home was undertaking a programme of redecoration and refurbishment. Significant improvement had been made to communal and downstairs circulation areas. - The proprietors were in the process of extending the programme of entertainment, activities and outings. 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. Shipley Hall Nursing Home DS0000065551.V272824.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 Shipley Hall Nursing Home DS0000065551.V272824.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): 3 Residents benefited from assessments of their needs both before and upon admission. EVIDENCE: At the time of the last inspection concerns had been expressed that service users had been admitted without current assessments and there was evidence that the home had been unable to meet the needs of some service users. Since this time there had been a change of ownership and some applications had been made for variations of registration to enable the home to admit residents who had needs outside the home’s registration. These applications had been accompanied by comprehensive assessments. Shipley Hall Nursing Home DS0000065551.V272824.R01.S.doc Version 5.0 Page 9 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 Progress was being made in the formulation of care plans and their implementation. Arrangements to improve the safety of drug administration had not been completed. EVIDENCE: At the time of the last inspection care plans were found to be based on physical and health needs and rather than preferred lifestyles and social needs. As a result of concerns there had been evidence that care plans had not been carried out as specified. Since the change of ownership on-going attention was being paid to revising care plans and their implementation. Recent concerns about meeting the needs of residents with higher level needs were assessed by nursing professionals. Progress made was noted and further advice given. The home had previously been subject to a number of complaints about moving and handling practice and the person in charge had ensured that all staff had received moving and handling training. Shipley Hall Nursing Home DS0000065551.V272824.R01.S.doc Version 5.0 Page 10 At the time of the inspection the home was at the point of changing pharmacy provider. Medication was reviewed frequently by GPs. Mediation was held in the medication trolley with the exception of controlled drugs which were held in a CD cupboard. Records were maintained of administration including coded records where medication was not administered. Some residents’ drugs records included their photographs but the majority did not. It was noted that for one resident who was a recent admission the medication record was hand written and was neither signed nor counter signed. Where the GP changed medication over the telephone this was recorded and the GP visited within 48 hours and signed the records. All qualified nurses and senior care staff had received training in the administration of medication. Shipley Hall Nursing Home DS0000065551.V272824.R01.S.doc Version 5.0 Page 11 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, 15 In the process of improving the quality of care provided to residents, the home had not achieved a demonstrable link between the expressed preferences of residents for their daily routines and individual care plans EVIDENCE: At the previous inspection levels of activity in the home had been low and concerns had been expressed about both standards of care and daily routines. It was alleged at that time that residents sometimes stayed up very late at night. This was not their own choice but through staffing shortages,. At the time of the current inspection an allegation was made that the registered person had instructed night staff to ensure that a proportion of service users were got up before they went off duty. As a result residents were said to be woken as early as 5 am in the morning. On the second day of inspection, the inspector arrived at the home at 7.30am instead of the arranged time of 10am. At that time three residents were seen to be dressed and seated in a downstairs lounge. Two were at that time dosing in a chair. Elsewhere in the home two residents were found to be in their rooms but not in bed and a third resident was clearly awake and listening to breakfast TV. The registered person who was on duty at this time indicated that attention was given first to residents with continence needs in the interests of their personal comfort and Shipley Hall Nursing Home DS0000065551.V272824.R01.S.doc Version 5.0 Page 12 maintaining tissue viability. Later discussion with some of the residents who were found to be in the lounges earlier elicited no complaints about early rising although it was not clear that that they were sufficiently oriented to be aware of the time. Levels of activities in the home had previously been low because of low levels of staffing but at the time of the inspection some residents indicated that the number of outings and activities had improved. The responsible person identified a range of events and activities over the Christmas period. Residents meetings had been introduced to the home. One resident who had lived in the home for some years indicated that there had been major difficulties with the change of ownership of the home and almost all the existing staff group had left the home. However the “dust had settled” and changes introduced had been for the good. A number of residents indicated that the care given by staff working in the home was to a good standard. Another resident, more recently admitted made it clear she had not settled and did not identify any activities or outings. Since the last inspection the kitchen area had been redecorated and looked cleaner and fresher. The home had a two week rotating menu which was said to be under review. Choice was offered within the menu and at breakfast cooked breakfast were available. Hot teas were on offer three days a week. Diabetic and soft diets were available and one resident had PEG feeding. Feedback on menus had been received at the residents’ meeting and menus were being reviewed in response to this. Some residents were positive about the quality of food and referred to improvements already made. Shipley Hall Nursing Home DS0000065551.V272824.R01.S.doc Version 5.0 Page 13 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): 16,17 The home experienced high levels of complaints both before and after the change of ownership, the former reflecting concerns about the care of residents and latterly complaints about the management of the home. EVIDENCE: Prior to the change of ownership and at the time of the last inspection, complaints were made about the care of residents, including two adult protection allegations. The home had not responded appropriately to complaints or adult protection allegations and staff in the home had shown inadequate understanding of adult protection procedures. Since the change of ownership 6 staff members had received training in adult protection and this was ongoing. Following the change of ownership a number of complaints had been received about the treatment of staff, the majority of these being anonymous complaints. Some complaints were on issues covered by legislation other than the Care Standards Act. In other instances the information given was not sufficiently specific for detailed investigation to take place. In all other instances the results of investigation were brought to the attention of the registered person and the complainant where possible. One complaint was made about the care and treatment of one resident. Following resolution of the complaint, the inspector interviewed the service user at the time of inspection who confirmed satisfaction with the service Shipley Hall Nursing Home DS0000065551.V272824.R01.S.doc Version 5.0 Page 14 provided. Another complaint investigated at the time of inspection was in part unresolved. Concerns had been expressed at the home’s ability to meet the mental health needs of some service users. The registered person indicated that she had received training on the care of people with dementia and that she giving staff training to staff. Shipley Hall Nursing Home DS0000065551.V272824.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): 19,26 The home is maintained to a good standard with a programme of redecoration being progressed quickly. EVIDENCE: The home is set in a rural setting with extensive grounds. These were maintained in good order and had an accessible seating area. Since the last inspection a programme of redecoration had been implemented. This included the redecoration of communal and corridor areas on the ground floor and the kitchen. The registered provider had plans to redecorate and renovate the whole home. A programme to replace carpets and furniture was part of the renovation scheme and evidence of progress was seen on this inspection. Some replacement of carpets had taken place and the program to replace old or damaged furniture had progressed but was not completed. Risk assessments had been undertaken on radiators, and work to cover radiators had been completed but for one radiator. A ground floor hairdressing room had been updated and provided with comfortable furniture to provide a smoking room for one resident. Shipley Hall Nursing Home DS0000065551.V272824.R01.S.doc Version 5.0 Page 16 The home was maintained to a clean condition and was much brighter and lighter following changes in colour schemes. The home had five separate communal areas. Shipley Hall Nursing Home DS0000065551.V272824.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): 27,2930 Residents are protected by staff who are recruited subject to appropriate checks. Staff are offered training and provided in numbers adequate to the needs of residents. EVIDENCE: At the previous inspection staffing levels had been low and sickness levels were high. This had significantly affected care practices within the home. Since this time additional staff including registered nurses had been recruited. At the time of this inspection staffing levels were to a satisfactory level and were as recorded in the rota. As noted elsewhere in this report there had been a major change over of staff in the weeks since the change of ownership of the home with only two staff from the previous group remaining in employment. A number of anonymous complaints had been received about the treatment of staff members by the registered person, the majority of which could not be resolved. Some elements of these complaints were grievances, which were matters of employment law. Three staff files were inspected. These demonstrated that recruitment procedures were undertaken which included the taking up of references and the completion of CRB checks. In one instance the full employment history of the applicant had not been included in the applications. Some overseas adaptation and qualified nurses were employed. Evidence was held of identity, Shipley Hall Nursing Home DS0000065551.V272824.R01.S.doc Version 5.0 Page 18 work permits and information from the NMC. Records were retained of training begun or completed. At the time of the inspection, 3 care staff had completed NVQ training, one to level NVQ3. Three staff members were currently undertaking training including one staff member who was undertaking an advanced health and social care course. 6 staff members were said to be ready to enrol on an NVQ course. 7 qualified nurses were employed in the home. Shipley Hall Nursing Home DS0000065551.V272824.R01.S.doc Version 5.0 Page 19 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, 33,35,36,38 Service users have not benefited by a stable staff group. The safety of residents has been improved by the provision of a programme of health and safety training and attention to health and safety issues within the building. EVIDENCE: Since the change of ownership of the home, the acting manager had left her employment. One condition of registration was that the registered person should ensure that the home had a registered manager. At the time of the inspection the registered person was undertaking the management of the home. She had extensive previous experience as a registered manager and stated her intention to continue management of the home to pursue her agenda for change. This would require the instatement of another Director as responsible person. Shipley Hall Nursing Home DS0000065551.V272824.R01.S.doc Version 5.0 Page 20 The responsible person has been responsible for making significant changes to practices in the home and some clear comments were made by service users indicating that changes were for the better. However the implementation of those changes resulted in very high staff turnover and a number of complaints about the management style and practice within the home. Care should be taken to ensure that change was accompanied by good training and staff support systems in order to reduce high staff turnover. The responsible person indicated that resident meetings had been introduced and that formal systems to seek the views of family supporters as well as residents would be in place by the end of January. At the time of the last inspection there was no system of staff supervision in the home. There was no evidence within staff records that such a system of formal supervision had been introduced. The home had systems in place to hold and record the personal monies of residents. Each person’s cash was held separately. Full records were kept of all transactions and the running balance and receipts were retained. There were two signatures for transactions. No-one working in the home acted as an agent for any resident. It was noted that the local authority paid both fees and personal allowances into the home’s business account but the responsible person indicated that the allowance was given out as cash. Where monies accrued to more than £100, the excess was sent to family members for them to act on the resident’s behalf. The fire Officer visited the home on 21/12/05 and included in his report was a requirement to pay attention to door seals and advice on proposed changes to the kitchen/dining areas. The proprietor indicated that work would be undertaken within the required timescale. Alarms, emergency lighting and fire equipment has been appropriately maintained. The Environmental Health Officer visited in October 2005 and requirements of that report had been met. There was evidence in staff files that considerable progress had been made in a short time on staff training. All staff members had received fire training and 12 staff had received training in food hygiene in December, 15 staff had received moving and handling training in November and 17 staff had received training in infection control, also in November. It was anticipated that Health and Safety training would be completed by February 2006. Shipley Hall Nursing Home DS0000065551.V272824.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 2 X 3 Shipley Hall Nursing Home DS0000065551.V272824.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 must ensure that photographs of residents are included within their medication records. The registered person must ensure that the written care plan is established after consultation with the service user and/or their representative and responds to their preferred routines. The responsible individual must formalise management arrangements for the home and ensured that an alternative responsible individual is put forward. The registered person must ensure that there as systems in place to offer formal (and recorded) staff supervision. Timescale for action 31/05/06 2 OP12 15(1) 30/06/05 3 OP31 10 31/05/06 4 OP36 18(2) 30/06/06 Shipley Hall Nursing Home DS0000065551.V272824.R01.S.doc Version 5.0 Page 23 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 OP16 Good Practice Recommendations The registered person should review the home’s complaints procedure ensuring that staff as well as service users and their representative are aware of these procedures. The registered person should review the home’s grievance procedures to ensure that processes comply with employment legislation. 2 OP29 Shipley Hall Nursing Home DS0000065551.V272824.R01.S.doc Version 5.0 Page 24 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 Shipley Hall Nursing Home DS0000065551.V272824.R01.S.doc Version 5.0 Page 25 - 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. 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