Inspection on 28/07/08 for Shipley Hall Nursing Home

This inspection was carried out on 28th July 2008.

CSCI found this care home to be providing an Adequate service.

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 27/04/07

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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Shipley Hall Nursing Home The Field Shipley Heanor Derbyshire DE75 7JH Lead Inspector Helen Macukiewicz Unannounced Inspection 28th July 2008 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.V369120.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.V369120.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 shipleyhall123@aol.com 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.V369120.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 transferrable to any other service users. 27th April 2007 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. The manager told us that the current range of fees is from £345.52 to £675 per week. A copy of the last Inspection report was seen in the foyer. Further copies of this report can be obtained from www.csci.org Shipley Hall Nursing Home DS0000065551.V369120.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. There is currently no manager registered with us for the home. The director of the Company who owns the home is the proposed manager and was in post at the time of this visit. As a consequence, reference throughout this report to ‘the manager’ refers to this person. This Inspection was unannounced and lasted 8.5 hours during one day. No pre-inspection questionnaires were received from people living in the home. The Manager had completed a self-assessment of the home and information from this was used in the planning of this inspection. Computer held records of all contact between the Home and the Commission for Social Care Inspection since the last Inspection were also referred to in the planning of this visit. During this Inspection discussion with people who use the service and their relatives took place. Time was spent in discussion with the Manager and staff. Four care files for people living in the home were looked at in detail and their care was examined to see how well records reflect care practices within the home. Relevant records belonging to the home were also examined such as complaints and policy documents. A brief tour of the home took place including some bedrooms. An interim unannounced random Inspection took place on 25th June 2008. The purpose of this visit was to use our inspection powers to undertake enquiries in relation to two complaints that had been received by us, so we could make a judgment as to whether the provider was complying with the regulations. The outcome of the random Inspection is not available as a public document but should be available from the Manager of this Home. Reference to the Inspection and any requirements will be made in this report where necessary. Throughout this report use of the terms ‘us’ and ‘we’ refers to the Inspector and/or the Commission for Social Care Inspection. What the service does well: People have an assessment of needs before moving into the home, which means that there is less chance of people being admitted inappropriately. People told us they were happy with their choice of home. Shipley Hall Nursing Home DS0000065551.V369120.R01.S.doc Version 5.2 Page 6 People told us they were happy with the care they received. One person described it as ‘marvellous’. Relatives were very happy with the communication they receive from staff, providing them with updates about the person’s care and treatment. People and their relatives told us that the food is ‘very good’. People told us they like the fact that the environment is homely and described it as a ‘home from home’ and ‘very clean’. People told us that staff are very friendly and welcoming. What has improved since the last inspection? What they could do better: Better recording and review of care needs is required to ensure care needs are not overlooked. Better systems for the management of medications are required to keep people safe. Better planning for social needs is required to ensure care in this area is person centred. Staff recruitment systems need to be tightened to ensure that people are protected from potentially unsuitable workers. Staff practice needs to be improved so that it promotes the dignity of people living in the home. The management of health and safety needs to be tighter and better evidenced in order to keep people safe. Shipley Hall Nursing Home DS0000065551.V369120.R01.S.doc Version 5.2 Page 7 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.V369120.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 Shipley Hall Nursing Home DS0000065551.V369120.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3. Standard 6 did not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pre-admission procedures ensure that people are admitted appropriately to the home. EVIDENCE: We looked at the information provided about the service contained within the Statement of Purpose and Service Users guides. The manager told us she was updating these to reflect current practices and contact points. She agreed to send us copies once revised so we could check they contained the right information. We asked a relative about whether they had received the right information before admission. They told us that they had. Two relatives confirmed that the manager had visited to carry out a pre-admission assessment of the person, to see if their care needs could be met, before they were admitted to the home. Shipley Hall Nursing Home DS0000065551.V369120.R01.S.doc Version 5.2 Page 10 In her completed pre-inspection self-assessment the manager told us ‘a preadmission assessment is carried out. Service users are encouraged to come and spend time with us and a steady move is made with minimal disruption. Family are encouraged to personalise the bedroom before the anticipated day of movement. Our care files are reflective of the above. All information is insitu’. We looked at care files. These did contain an assessment of need for planned admissions that had been carried out by a registered nurse. For one emergency admission, there was a Social Services assessment of need that had been obtained prior to admission. This helped the staff to decide whether the persons’ needs could be met by them and reduced the risk of inappropriate admissions to the home. Shipley Hall Nursing Home DS0000065551.V369120.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Gaps in the recording of care needs and medications have the potential to adversely affect the wellbeing of people living in the home. EVIDENCE: We looked at care files for 4 people living in the home. Each contained a plan of care and risk assessments in areas such as skin condition, moving and handling and nutrition. There were documented reviews of risk assessments and these supported that staff were monitoring existing and potential risks. We found that care plans were not being updated as regularly as required and did not contain enough information to provide care staff with direction when giving care. One care plan contained two problems that had resolved but were still included in the current care plan. Some identified needs were not being reviewed at least monthly. One person had 3 wounds, each with a dressing on. There was no care plan for any of these wounds. One person had developed a Shipley Hall Nursing Home DS0000065551.V369120.R01.S.doc Version 5.2 Page 12 pressure sore, there was no actual or preventative care plan for this, despite staff recording in carers records that they had attended to the wound and provided a specialist mattress. Where people had displayed aggressive behaviour, there were monitoring charts in place but no care plan in the persons file for what behavioural approaches staff needed to take or what care was needed to keep people safe (staff and people living in the home). One person had a known behaviour of making false allegations against staff, there was no protection plan in place within the care plan to ensure both staff and the person were protected, and to indicate what action needed to be taken in relation to safeguarding referrals following allegations. In her completed pre-inspection self-assessment the manager told us ‘nursing staff review (care) monthly and wherever possible with families. Six monthly/annual social services reviews and signatures are sought if possible’. We saw that some care files contained signatures to support that people were being involved in reviews of their care. One person told us they knew the content of their care plan. However, not all people living in the home had the capacity to agree to plans of care and the manager said that she was trying to gain consent from relatives where this was the case. Documentation within the home and discussions with relatives showed that people were receiving medical attention and attending outpatient’s appointments as needed. Staff were observed correctly using lifting equipment when assisting people to move. Visitors told us they were particularly pleased with the amount of updates they get about their relatives care and changes to their medical condition. One said ‘I am always kept informed’. During our random inspection visit on 25.6.08 Those people who were more independent said they had noticed shortfalls of staff recently but that it had not affected their care, one told us they were ‘very happy it is a good home’. Those people who needed more physical help told us that they had to wait for their care needs to be met. One person said they had to wait for someone to take them outside the home, another said they had to wait to be taken to the toilet and to be taken to/from the dining table at meal times. On this occasion there were sufficient staff around to ensure people did not have to wait for care. People told us they were happy with the care and services provided. One person told us it was ‘wonderful-marvellous’ and that they did not want to leave the home, as they were really happy living there. One relative told us that they would ‘live there myself’. Both people living in the home and their relatives all said that staff treat people with respect, uphold their dignity and rights to privacy. In her completed pre-inspection self-assessment, the manager told us ‘new medications fridge is now insitu and the temperatures are recorded’. We saw the new fridge. Medications stored inside the fridge were labelled and stored at the correct temperature. Shipley Hall Nursing Home DS0000065551.V369120.R01.S.doc Version 5.2 Page 13 From checks on numbers of tablets in the home and discussion with staff and relatives, there was no evidence that people had not received the correct medications. However, there were a number of gaps in recording standards that needed to be addressed. Some medications had not been signed for on the medication administration charts. The quantity of medication being brought into the home was not always recorded correctly. Staff were not always recording the exact number of tablets given where a variable dose prescription applied. Hand written entries to medication records were not always signed. Some medicines were not stored correctly. Some water for injections had expired and were destroyed during the inspection. Three lots of medications were stored incorrectly in baskets within the treatment room. The nurse in charge told us that an additional medicines trolley had been purchased. This was of sufficient size to ensure medications were stored correctly and the nurse agreed to ensure these were stored securely. One person had run out of their painkillers and told us they were in pain. The manager had obtained a supply on the day of this visit, but they had been without adequate pain relief for 2 days. The issues regarding medication were discussed with the manager at the time of this visit, she took action on all of the issues identified during the Inspection and this showed us that she was willing to ensure that people living in the home would be kept safe. Shipley Hall Nursing Home DS0000065551.V369120.R01.S.doc Version 5.2 Page 14 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): Standards 12-15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have some social needs met but care in this area is not always planned and delivered in a person centred way. EVIDENCE: People living in the home and their relatives told us that the staff provided some day to day activity and that entertainers visited the home. There had been a summer fayre earlier in July and there was an activities diary with pictures showing various events that had taken place throughout the year. In her completed pre-inspection self-assessment the manager told us ‘Some service users go out with their families. We have a devised individualised activity sheet, which involve families. Entertainers have been booked. Social group meetings occur regularly’. There was some acknowledgement of peoples’ individual social needs and choices in assessments recorded in care files. These also stated preferred daily routines. However, this information was not being used to form a personalised Shipley Hall Nursing Home DS0000065551.V369120.R01.S.doc Version 5.2 Page 15 care plan to meet social/cultural or spiritual needs. Because of this approaches to such needs were not planned in a person-centred way. There were plenty of relatives visiting on the day of the Inspection. People living in the home told us they had freedom of movement both in and around the home, but would like to go out more. In her completed pre-inspection self-assessment the manager told us ‘our menus are planned with consultation plus the cook goes round to ask individuals about their preferences = 5 choices/variations’. People told us that in their opinion the food was ‘very good’. Shipley Hall Nursing Home DS0000065551.V369120.R01.S.doc Version 5.2 Page 16 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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are kept safe through staff training and procedures. Complaints procedures ensure that peoples’ rights are upheld. EVIDENCE: The home had three recorded complaints received since the last Key Inspection. We had received another three. Those three concerns raised to us resulted in us undertaking a random unannounced Inspection of the service on 25.6.08. On that occasion two complaints were partly substantiated. The manager had worked in co-operation with us to resolve the issues raised by the three complaints. People told us they were satisfied with the procedures for raising concerns. One relative told us ‘if I have a problems I see (the manager) and she sorts it’. There had been no safeguarding issues since the last Inspection. Safeguarding procedures were seen in the office and there was also a copy of the local authority procedures. Staff had received training in safeguarding adults. Staff files contained certificates to support this had recently taken place so staff were up to date about procedures to keep people safe. Shipley Hall Nursing Home DS0000065551.V369120.R01.S.doc Version 5.2 Page 17 Some equipment that carried a degree of restraint such as bedrails and wander mats had not been subject to a full risk assessment. Advice was give at the time about how this might be best achieved. Some peoples’ care files contained documentation to support that consent for use of such equipment had been sought. However, this did not include wander mats, which could also be perceived as having a restraint element. Discussion took place with the manager about ways in which the staff could ensure compliance with the Mental Capacity Act. The manager told us she had attended training on this and had some documentation as a result. She stated it was her intention to cascade this training to all staff. Shipley Hall Nursing Home DS0000065551.V369120.R01.S.doc Version 5.2 Page 18 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): Standards 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 environment of the home enhances the quality of life for people living there. EVIDENCE: People told us they were happy with their environment. People had been able to personalise their bedrooms and bring in items of furniture from home. One person said it was ‘a home from home’. One relative said they had specifically chosen the home because it was like a persons own home and not too clinical in nature. Some of the bathrooms had been refurbished to a good standard. In her completed pre-inspection self-assessment the manager told us ‘We have won a bid from Business Link for a sensory therapy centre which will be completed by Shipley Hall Nursing Home DS0000065551.V369120.R01.S.doc Version 5.2 Page 19 July 2008! A mobile unit will be purchased for those service users who cannot access the sensory therapy room. The top conservatory will be a multifunctional room with heated flooring, relaxing areas and therapy areas. All fire doors have had magnets applied where required. The kitchen has been refurbished to meet the needs of the home’. All these projects had, or were nearing completion on the day of the visit. Although areas of the home would still benefit from refurbishment and re-painting there was evidence to support that the manager was striving to make improvements in this area. We noticed that the people sitting in small lounge No9 did not have access to a staff call. There was a staff call point on a wall but only one person was physically able to walk to that point. People told us they shouted when they wanted assistance and that staff regularly walked past that area. However, people would be safer, and care delivery more dignified, if they had access to a staff call point especially during busier times of the day. The laundry equipment was sufficient for the cleaning of soiled items and maintenance of infection control. All areas of the environment were clean and tidy. One relative told us that the home ‘is very clean’. Shipley Hall Nursing Home DS0000065551.V369120.R01.S.doc Version 5.2 Page 20 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): Standards 27-30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are cared for by sufficient numbers of experienced and well-trained staff. However, some approaches to care did not uphold peoples’ dignity. Gaps in recruitment had the potential to put people at risk of unsuitable workers. EVIDENCE: During our random inspection on 25.6.08 we found that the staffing rotas did not reflect what people were actually working. Therefore it was hard to assess whether people were receiving care from sufficient numbers of skilled and trained staff. However, on this visit the staffing rotas showed sufficient levels of staff had been provided and people did not express any concerns about this area. One relative told us ‘there are always staff around, supervising and assisting’ another said ‘staff are always around, combing hair, seeing to nails’. The random inspection also highlighted that not all staff had a proper induction, which put people living at the home at risk from inexperienced workers. An immediate requirement was made at the time to ensure adequate induction of staff. On this visit, we saw induction records for new staff employed and new staff told us they had been given the information they needed. Shipley Hall Nursing Home DS0000065551.V369120.R01.S.doc Version 5.2 Page 21 The manager was not present during the random inspection visit and no other staff had access to the records. An immediate requirement was made at the time of the Inspection, to ensure access to records could be gained at all times, to enable us to assess whether people were being kept safe from unsuitable workers. The manager was present during this visit and gave us access to staff records. Recruitment files showed that staff were mainly subject to the necessary pre-employment checks with the exception of the following: • • A medical questionnaire was not requested to find out whether the person was physically and/or mentally fit to carry out the work. Written verification as to the reasons why a person had ceased working in positions with vulnerable adults was not obtained. General observations of staff showed they had good relations with people in their care, they generally explained to people what they were going to do when assisting them. Both relatives and people living in the home told us that the staff were ‘lovely’. One relative said ‘the staff have always got a smile on their face’, another said ‘the staff make you feel welcome and are all friendly’. However, we found that some staff were not communicating with people in an appropriate manner and were not always using a person-centred approach during their work. Staff referred to some people who needed higher levels of supervision to maintain their safety as ‘wanderers’. In conversation one staff member was heard saying to a person living in the home ‘be a good girl-come on’. One member of staff did not appear to know how to approach and manage a persons’ behaviour resulting in the person becoming increasingly agitated and confused. Two members of staff used inappropriate verbal and non-verbal communication when assisting the same person. This was brought to the attention of the manager at the time, for her action. Staff training records, notices around the home and discussions with staff themselves all supported that they were receiving the required amount of mandatory training and updates. Most staff had been trained to National Vocational Qualifications (NVQ) levels 2 or 3 in care subjects. The manager told us that new staff employed were expected the commence NVQ’s. Some staff had been scheduled to commence theirs by September 2008. Shipley Hall Nursing Home DS0000065551.V369120.R01.S.doc Version 5.2 Page 22 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): Standards 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home is user-focused. Gaps in the management of health and safety have the potential to put people at risk. EVIDENCE: The manager is a registered nurse with 9 years of management experience within a care home setting. She was completing her registered managers award. She had successfully applied for an extension to apply for registration with us. However, she had yet to re-submit her application, which she is required to do. Shipley Hall Nursing Home DS0000065551.V369120.R01.S.doc Version 5.2 Page 23 The manager undertook periodic quality assurance. In her completed preinspection self-assessment the manager told us ‘We hold social group meetings, liaise with residents and send out questionnaires’. Completed surveys that had been returned were seen. Relative’s comments were mostly favourable. One survey recorded ‘staff are all very helpful and kind’. There were satisfactory procedures in place for handling peoples’ personal allowances. Money was stored securely. People told us they were happy with the way the manager handled their money and that they always had access to it. Some service records for equipment used in the home were seen. Most were up to date with the exception of the fire extinguishers where there was no evidence that they had received an annual maintenance check. The manager could not locate the full environmental risk assessment of the home, but she said she had recently completed one. She agreed to send us a copy. A fire risk assessment of the building had been completed and was available. However, we noticed that there were a lot of flammable products stored in bathroom 21. This room had no fire detection, as it was not a designated storage area. This compromised the fire safety of the building. Shipley Hall Nursing Home DS0000065551.V369120.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 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 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 2 Shipley Hall Nursing Home DS0000065551.V369120.R01.S.doc Version 5.2 Page 25 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 OP8 OP7 OP12 Regulation 15(1)(2)( b) Requirement People must have a plan of care that clearly details all care needs, including social care needs and provides direction for staff as to what actions they need to take. This must be subject to regular review and updated as peoples care needs change. This is to ensure care needs are not overlooked and people are kept safe. 2. OP9 13(2) • • All medications given must be signed for. The quantity of medications being brought into the home must be accurately recorded so all medications can be accounted for. The exact number of tablets given must be recorded each time where a variable dose prescription applies. Hand written entries to medication records must always be signed. 31/08/08 Timescale for action 30/09/08 • • Shipley Hall Nursing Home DS0000065551.V369120.R01.S.doc Version 5.2 Page 26 3. OP19 13(4)(c) 4. OP29 19 and schedule 2. 5. OP30 18(1)(a) 6. 7. OP31 OP38 8 13(4)(c) All medications must be stored correctly and safely. • Systems for the ordering and supply of medicines must ensure that people always have the medications they are prescribed. • Systems must be in place to ensure expired medications are identified and removed. • Systems must be in place to audit the management of medicines within the home to ensure safety in this area. People living in the home must have access to a staff call system to ensure their safety at all times. People must not be employed at the home until all necessary preemployment checks have been undertaken. This is to ensure people are protected from potentially unsuitable workers. Staff must be trained in personcentred care. They must be trained to communicate with people in an appropriate manner and use a person-centred approach during their work. This is to ensure peoples’ dignity is upheld. The manager must apply for registration with us. You must supply us with evidence that the fire extinguishers have been serviced. Also that a general risk assessment for the home has occurred. The flammable items must be removed from bathroom 21 to make this area safe. • 31/08/08 31/08/08 30/09/08 31/08/08 31/08/08 Shipley Hall Nursing Home DS0000065551.V369120.R01.S.doc Version 5.2 Page 27 This is to ensure the safety of people living in the home. 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. 2. Refer to Standard OP12 OP18 Good Practice Recommendations Activities must be person-centred and delivered in such a way as to maximise peoples’ independence and choice. Wander mats should be subject to risk assessment and consent. Shipley Hall Nursing Home DS0000065551.V369120.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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.V369120.R01.S.doc Version 5.2 Page 29 - 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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