Inspection on 27/04/07 for Shipley Hall Nursing Home

This inspection was carried out on 27th April 2007.

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

Shipley Hall Nursing Home 13/07/09

Shipley Hall Nursing Home 28/07/08

Shipley Hall Nursing Home 27/04/06

Shipley Hall Nursing Home 12/12/05

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 Brian Marks Key Unannounced Inspection 27th April 2007 09:00 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.V335228.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. Shipley Hall Nursing Home DS0000065551.V335228.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shipley Hall Nursing Home Address The Field Shipley Heanor Derbyshire DE75 7JH 01773 764906 F/P 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 Vacant 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.V335228.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 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. One DE(E) place for service user named in notice of proposal letter dated 09 January 2006. Registration to include the accommodation of one named service user PH (as specified on the notice of proposal) under the category PD, not transferable to any other service users. 27th April 2006 Date of last inspection Brief Description of the Service: Shipley Hall is a care home with nursing, set in attractive parkland grounds, with a pond and gardens that attract a variety of wildlife. The home is a converted, extended building, dating from the turn of the century, and provides facilities for thirty residents. There are five day/quiet rooms, which include two conservatories overlooking the garden areas. Accommodation is provided on ground and first floors, with passenger lift and staircase access to the first floor. An additional stair-lift provides assisted access to one of the first floor bedrooms up a short flight of stairs. 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. All rooms are equipped with a call system and residents are encouraged to personalise their rooms if they wish. Support services are in place for the nurses working at the home, with a choice of General Practitioners, and chiropody, dental, optician and other services arranged as appropriate. A hairdressing service is provided at the home. The current range of fees is from £333 to £555 per week. Shipley Hall Nursing Home DS0000065551.V335228.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that took place at the home over a period of a day. Additionally, time was spent in preparation for the visit, looking at previous inspection reports and other relevant documents and preparing a structured plan for the inspection. At the home, apart from examining documents, care files and records, time was spent speaking to the manager and seven of the staff working at the home during the visit. The care records of four people who use the service were examined in detail and two of these were interviewed along with four others and four visitors who were at the home during the day. Since the last Key Unannounced inspection of the home on the 272 April 2006 a Random Unannounced inspection visit was carried out on 8 November 2006 to further evaluate progress with requirements previously made. What the service does well: Everybody spoken to at this inspection – residents, visitors, and staff – was very positive about the care being provided at the home and how the changes brought in over the past year had improved things for the people living and working there. Although change has been difficult for some staff, those spoken to talked of the good morale in the staff group and about how everyone wants to work together to make the home’s residents comfortable and safe. A programme of improvement of the physical aspects of the home has continued and with 5 communal rooms, it give the opportunity for small social groups of compatible residents with similar interests and preferences to spend time together. The home is situated within parkland and provides extensive grounds with accessible seating area. Staffing levels have been retained to a satisfactory level and residents confirmed that there is always somebody around if they need them. The impact of the new proprietor in bringing about these changes has been central in the improvements that have occurred at the home during the past eighteen months. Residents and visitors who spoke to the inspector indicated high levels of satisfaction with life at the home. ‘I’m not restricted by the home but by my condition’. ‘I looked at other homes but was impressed with this one and moved in straight away’. ‘She’s turned things round in a big way; its brilliant’. Shipley Hall Nursing Home DS0000065551.V335228.R01.S.doc Version 5.2 Page 6 ‘My family and I visited many homes in the area but because of the welcome we received here we were in no doubt which to choose’. The home is like a second home to my family and me’. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Shipley Hall Nursing Home DS0000065551.V335228.R01.S.doc Version 5.2 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.V335228.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home have their care needs assessed at the time they move in and can be reassured that the home will care for them properly and safely. EVIDENCE: The documentation for assessment of resident needs, previously in use, has continued in place for all of the current residents and the files of the four most recently admitted were examined, including someone who had been admitted two days before the inspection. All had ‘front sheet’ details and these were linked to an initial assessment of the person’s needs or a completed referral sheet. Where the person has been admitted by referral from a Social Services professional a detailed package of assessments, background history and general care plan is usually supplied, but for the person admitted to the home just before the inspection this did not occur until that day. Staff would have been working with him without a full understanding of his needs and his welfare could be affected. In all other cases, a further more detailed assessment had been carried out, along with further additional assessments of areas of risk such as falls, skin breakdown and pressure sores, nutritional Shipley Hall Nursing Home DS0000065551.V335228.R01.S.doc Version 5.2 Page 9 needs and safe moving and handling. These support the staff in working consistently and safely. The home does not offer an intermediate care service so Standard 6 does not apply. Shipley Hall Nursing Home DS0000065551.V335228.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning arrangements at the home promote safety and consistency in caring for residents and improvements have been made to the system of managing residents’ medication so that they are fully protected. EVIDENCE: The care records of four residents were examined in detail and these have been completed to a satisfactory standard. The care plans identify key problem areas and link directly to the daily event records and all areas of care practice are routinely evaluated on a monthly basis and revised where necessary. One file contained a particularly detailed plan describing the care of someone with serious pressure sores and how the outcomes of that care had been linked with support from outside specialists. The standard of documentation was however variable, with only one file containing a very detailed – ‘more holistic’ – picture of the person being cared for. The inclusion of social and psychological factors and histories allows staff to care for the residents in a more complete way. All residents spoken to or their relatives commented that staff care for them in ways that respect their dignity and privacy and this was underpinned by entries in the care plans examined. Shipley Hall Nursing Home DS0000065551.V335228.R01.S.doc Version 5.2 Page 11 Examination of the storage and administration arrangements of residents’ medicines was satisfactory and requirements from the last inspection have been attended to. Records in the care files examined indicated regular contact with outside health care services and people spoken to confirmed that they saw their GP or other specialists promptly and without any problems. The systems in place fully safeguard residents. Shipley Hall Nursing Home DS0000065551.V335228.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities for residents to engage in leisure and social activities have continued to improve, and the catering of the home is a service viewed very positively by them. EVIDENCE: Since the last inspection two care staff have been allocated time to improve activities and social life at the home and they spoke enthusiastically about the progress they have made so that residents are more involved with the home. Appropriately active lifestyles are encouraged and residents and relatives have continued to be able to air their views about events at a home at irregularly arranged meetings, so that this subject is regularly discussed. Routines around the home are quite flexible and people spoken to were quite clear about being able to please themselves around the home, within the limits of safety. Contact with families is encouraged through an ‘open door’ policy, and good numbers were seen at the home during the inspection. Those spoken to were positive about relationships with the home’s staff: ‘Staff are very welcoming and no problems are left unattended to’. ‘It’s not just how they look after him but what I see around he place that is good’. Some are very regular in their visits and support the care activities of the staff in practical ways. Shipley Hall Nursing Home DS0000065551.V335228.R01.S.doc Version 5.2 Page 13 During a visit made to the kitchen and from discussion with the cook it was evident that good standards in the catering service have continued, but some of the recommendations made at the last visit by the Environmental Health Officer are still to be dealt with and safety is not completely assured. A clear choice was available at the main meals, according to the 2-week menu, and this was conformed by comments from residents who were very positive about the quality of food served. A cooked choice is available at afternoon tea and at some breakfasts. Special arrangements are made by the cook for people with special dietary needs, including people with diabetes and those who need softened food. The cook is receives information about the nutritional needs of people as they are admitted and there have been improved arrangements for kitchen staff to spend time in direct contact with residents so that they are informed about the impact that the catering arrangements make. Shipley Hall Nursing Home DS0000065551.V335228.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home responds to complaints made by residents and their representatives according to a written procedure, and aims to protect residents from harm. EVIDENCE: Since the last Unannounced Key inspection two formal anonymous and two informal complaints have been received and investigated by the proprietor, and the outcomes dealt with satisfactorily. Overall the level of complaints about the home’s practice has reduced considerably in the past year, reflecting on the more settled atmosphere currently being experienced at the home. During last year, there have been no instances of the use of the statutory procedures for safeguarding vulnerable people and staff have received training in respect of their responsibilities for recognising and reporting abuse. The proprietor has been able to demonstrate a pro-active approach to and clear understanding of this subject, developed from practical experience. Shipley Hall Nursing Home DS0000065551.V335228.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical state of the home produces a satisfactory and safe environment in which to live and work, although there is still work to be done in the kitchen. EVIDENCE: From a tour of the communal areas and kitchen at the home, the standard of maintenance was found to be generally satisfactory with the planned programme of continued redecoration and improvement ongoing since the last inspection, including redecoration in all communal areas: All bedrooms on the ground floor have been refurbished. A shower room has been refitted and refurbished. Rearrangements to the office, communal rooms and bedrooms have taken place. Blinds have been fitted in the conservatories. Arrangements in the kitchen have been changed. As noted previously the recommendations made at the last visit by the Environmental Health Officer are still to be dealt with and safety is not Shipley Hall Nursing Home DS0000065551.V335228.R01.S.doc Version 5.2 Page 16 completely assured. Also the food storage areas remain separate from the kitchen. The communal areas and bedrooms of the home visited during this inspection were clean and tidy and free from odours. Residents and family members spoken to had no complaints about the laundry service of the home and all residents observed in the home wore clean and well-presented clothing. Shipley Hall Nursing Home DS0000065551.V335228.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of residents are met by a group of staff who are selected by a robust recruitment system and who are on duty in good numbers. Good standards of training and basic qualification have also been provided in order to improve staff performance. EVIDENCE: Evidence of increasing stability in the home’s staffing arrangements were noted and examination of the staff rota indicated that the previously agreed levels of nursing and care staff have been maintained and that there were no staffing vacancies at the present time. A good level of achievement has been made with training in the National Vocational Qualification level 2 and the target, set nationally, has now been achieved; more staff will have completed this by the end of the year. From examination of the records and talking to staff good levels of general staff training have been achieved in the past year and, as well as key areas in health and safety and safeguarding vulnerable adults, topics such dementia training, good nutrition and diabetes management have been covered by different staff. Staff awareness and standards of performance will be increased through this process. Examination of the personnel files of the staff recruited since the last inspection indicated a formal system in place, and the procedure required by law to check criminal records of new staff is now routinely followed. This had Shipley Hall Nursing Home DS0000065551.V335228.R01.S.doc Version 5.2 Page 18 been a cause for concern at the last two inspections and arrangements are now such that only suitable people are being employed at the home. Shipley Hall Nursing Home DS0000065551.V335228.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements in administration and management of the home have continued to be made by the proprietor/manager and the home is a safe place to live and work and reflects the wishes and preferences of the people that live there. EVIDENCE: The current proprietor of the home took over the home in the middle of 2005 and has been running it on a day-to-day basis since then. In the absence of a suitable alternative she has now decided to apply to register as manager and retain the role of Responsible Individual on behalf of her company also. She is a qualified nurse and has experience of this dual responsibility at the last home she owned; the application to register has been submitted to the CSCI. The proprietor/manager has at previous inspections stated her intention to ‘pursue an agenda for change’ and this has continued with the general support of everyone connected with the home. General administration of the home Shipley Hall Nursing Home DS0000065551.V335228.R01.S.doc Version 5.2 Page 20 remains good and systems have been replaced or improved. A brief survey of resident or relative views of the operation of the home has been carried out and the residents meeting has continued with staff support. Last year’s Annual Plan for the home has been successfully completed and a new one is being prepared. Audits of the arrangements for caring for residents’ money and the health and safety standards of the home were carried out and standards were found to be generally good. Systems for the formal support and monitoring of staff performance have been reintroduced but as this occurred only recently, the regularity required by law has not been assessed. Staff said that their morale is good at present and there is always help available in resolving problems as they arise; the atmosphere around the home was very positive at the time of the inspection. Staff also reported better communication and improvements in teamwork and that this had supported continuity of care to residents. Shipley Hall Nursing Home DS0000065551.V335228.R01.S.doc Version 5.2 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 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 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 3 X 3 Shipley Hall Nursing Home DS0000065551.V335228.R01.S.doc Version 5.2 Page 22 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 OP19 Regulation 23(5) Requirement The recommendations for action made at the last inspection by the Environmental Health Officer must be followed so that the physical arrangements of the kitchen are safe and hygienic. Timescale for action 30/06/07 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 OP2 Good Practice Recommendations Where an outside professional has supported someone to come and live at the home, the full range of information should be obtained to make sure that staff are working safely and consistently with the person, once they have been admitted. Arrangements in the kitchen should be reviewed in order to improve food storage, cooking and serving. All staff should receive 6 sessions of formal 1-to-1 supervision with a senior member of staff so that their work can be better monitored and supported. 2. 3. OP19 OP36 Shipley Hall Nursing Home DS0000065551.V335228.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V335228.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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