Inspection on 22/05/07 for Shipley Lodge

This inspection was carried out on 22nd May 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shipley Lodge 23/12/09

Shipley Lodge 26/06/06

Shipley Lodge 04/10/05

Shipley Lodge 21/04/05

Shipley Lodge 02/12/04

Shipley Lodge 10/06/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Shipley Lodge 94 Derby Road Heanor Derbyshire DE75 7QJ Lead Inspector Andrew Sales Key Unannounced Inspection 22nd May 2007 10:00 Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 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 Lodge DS0000039072.V341703.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 and Care Homes for Adults 18 – 65*. 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 Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shipley Lodge Address 94 Derby Road Heanor Derbyshire DE75 7QJ 01773 535212 01773 535212 shipleylodge@rethink.org www.rethink.org Rethink 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) Richard Edington Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Date of last inspection 26th June 2006 Brief Description of the Service: Shipley Lodge is a purpose built care home. It is situated in a residential area of Heanor close to local shops, public houses and bus routes. The home provides nursing care for up to sixteen people, eight males and eight females, aged 18 years upwards, who experience enduring mental health problems, although the majority are in the 18-65 year age group. People have opportunities to take part in daily living and social activities, and enabled to have a more independent lifestyle. The fees charged per week at this service are currently £973.69. Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started on Tuesday 22 May 2007, a visit to the service was conducted on 31 May 2007 at 10.00am. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. Where possible, we include evidence from other sources, notably District Nurses and Social Workers. We also use information gathered throughout the year, to support our judgements. This may include notifications from the provider, complaints or concerns and the pre-inspection questionnaire, which the provider is required to complete prior to a visit to the service. On this occasion we were unable to issues service user or staff questionnaires. This will need to change for future inspections to make sure that staff and service users have the chance to air their views and contribute to the inspection process. The primary method of inspection used during the visit to this service was ‘case tracking’. This involved selecting three people and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. We spoke to three people, who were able to give us their views about the service. We also spoke with two members of the support staff and, who were also very helpful. We spent part of the day discussing records, documents and policies with the manager. All of the key standards were inspected on this occasion. What the service does well: Shipley Lodge provides a range of activities to meet the needs of the people. This may include assisting people out to the shops and for pub meals, some people attend colleges and day care services. Some people are able to access community facilities independently, using public transport to get nearby facilities. All people have key workers and feel confident to discuss any issues with them. Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 6 The people spoken with during the inspection were complimentary about the standard of care provided. Routines are very flexible in the home and people are able to prepare meals with the assistance from staff. 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 Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are fully assessed prior to moving into the home and they are confident that the home is suitable for them. EVIDENCE: The support plans contained evidence that professional assessments are obtained regarding people needs prior to their being admitted. The manager develops with each person a plan based on the assessment that details any restrictions on freedom, services or facilities balanced with their needs. Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 9 People told us that they were able to visit the service and were shown what help was on hand to see if it was suitable for them. Staff told us that plans are discussed with people and attempts are made to ensure that they are in agreement with their plans. We saw evidence that where possible people are asked to sign the plan ensuring that they are involved in the plan. The manager and staff showed us how the home obtains specialist advise from health care professionals. This was supported by documentation in care plans. People also told us about visiting community health services, such as Community Psychiatric Nurses and doctor services. The induction program and training schedule was observed and this will help to ensure that staff are able to meet the needs of people admitted. The staff commented that the induction to the homes procedures and following training equipped them to provide a good standard of care. Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are assured that their needs are assessed and changing needs are reflected in their plan. People are supported to take risks and have an active independent lifestyle. EVIDENCE: The support plans contain adequate information to enable staff to understand their needs and ensure they maintain an independent lifestyle. Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 11 Support plans cover all aspects of the person’s daily life and provide clear information on how the person prefers to receive their support. There are risk assessments to ensure the safe participation in chosen activities We saw evidence that support plans are reviewed regularly by senior staff. We observed risk assessments in relation to maintaining independence and risks for all areas of daily living. Staff who spoke with us demonstrated a good understanding of the care planning process and the management of risk. The inspector spoke with people who were able to describe what they were supported with and how the staff approached this. We made observations throughout the day. People were seen coming and going from the building, preparing meals with staff and going about general day to day tasks. Staff described to us a variety of positive methods they used to interact with people who had difficulty in communicating. Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 13 12,13,15,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People take part in age appropriate activities, are part of the community and are able to maintain personal relationships with family and friends. People’s rights are respected and responsibilities recognised. EVIDENCE: We saw evidence where assessment plans identified what personal and domestic responsibilities people have. This went on to show and what staff support was required to help them do this, ensuring that the person was actively involved in the day to day running of the home. Two people were able to describe how they are supported with daily tasks within their accommodation and staff confirmed how they draw up a plan of assistance centred around the individual’s capabilities. People described how meetings take place frequently, where domestic and social issues are discussed. All of the people spoken with, told us they were happy with the level of activities within the home and outside. They commented that the philosophy of the home and the attitude of the staff enabled them to make choices and felt they were generally well respected. The staff reported that they encourage people to participate in events and outings. People told us this may include assisting them when out for pub meals, shopping, going to colleges or day care services. Some people told us they do this without the help of staff. People told us about day trips and holidays where they are able to express their preferences of where and who to go with. Staff said this benefits those who are less vocal and may not want to travel in a group. Two people said this a “wonderful place, we have en-suite rooms and staff respect our choices and privacy” Another person showed us his certificates he had been awarded at horticultural college, which he attends weekly. He said “ I really enjoy doing this and am so pleased to get these.” Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 14 Support plans showed us how staff promote and maintain people’s privacy and dignity. Staff spoken with clearly understood the importance of promoting this. We spoke with staff who showed us how people were involved in choosing the menu for the week or meals on the day. We saw that people were given a wide choice. We observed people preparing food with staff assistance, this is a flexible arrangement, people said “we can eat whenever we want to.” Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) Service users retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicines. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are protected by the home’s policies and procedures for dealing with medicines and receive their personal support as they prefer and require. EVIDENCE: The assessment records show that people are able to receive their support as they prefer to, or within their capabilities. Staff spoken with understood the Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 16 different needs and preferences of people and understood the importance of supporting people this way. The people we spoke with were able to describe what they were supported with and how the staff approached this. All the feedback we received from people suggests that the staff are courteous and understanding when supporting them with any task, whether personal care, practical tasks or social assistance. One person said the standards overall were ‘excellent’. Some people were keen to point out that staff would always do extra tasks when asked, but were always mindful of their independence. We observed care staff throughout the day undertaking a variety of support tasks with a professional and courteous manner. Staff commented that they felt the home promoted the independence of people consistently, throughout the induction, training programs and policies and practices. There was evidence in support plans and diary notes of people attending GP appointments and other health care visits as well as psychiatric advice being sought regarding people’s mental health and medication. The homes medication administration systems are well maintained. There is a policy and procedures for receiving, recording, storing, handling, administering and disposing of medicines. The home is registered with the local pharmacist and support and advice is obtained as and when needed. We observed medication records and noted evidence of medication reviews and updates. We were able to track information from the diary notes and support plan to the Medication Administration Records (MAR) sheets to show that appropriate action had been taken, following incidents or reviews. We looked at one person’s medication records. These reflected what was recorded and what was left in administration packs. We saw new risk assessments for each medication this individual was taking. These were detailed and provided clear guidance for staff. The manager showed us how individuals who wish to self –medicate can achieve this through different stages of supervised self-administration. Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People feel they are consulted. Systems are in place to safeguard people from abuse. EVIDENCE: Staff spoken with had a good understanding of the importance of enabling people to voice their complaints. All the people we spoke with said that they would speak to the manager if they were not happy with something. One person told us that he had experienced minor problems with a member of staff. He described how he spoke with the manager and that this problem was resolved. Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 18 We have received no complaints regarding this service and have no concerns in this area. There are clear policies and procedures for staff to follow in the event of a complaint. Staff spoken with had a clear understanding of what constituted abuse and what responsibilities they had to ensure people remained safe. People spoken with said that they felt safe in the home and staff were pleasant to them. Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is suitable for its stated purpose; accessible, safe and well maintained. Shipley Lodge provides people with a comfortable and spacious environment. Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 20 EVIDENCE: We looked at all of the communal areas and found them to be well furnished and maintained. All of the people told us they liked the homes décor and furnishings. They said they were pleased that the communal areas had been re-arranged following consultation with the manager and staff and now offer a quiet room to relax in. We looked at bathrooms, bedrooms and communal areas including lounges and the kitchen. These are all well kept, clean and free from any odours. Bedrooms are personalised and provide people with a pleasant space to relax in. People told us the gardens are pleasant environment for them to relax in. We were shown how people participate in cleaning their own personal accommodation, one person showed us how he enjoyed helping around the home with cleaning and at mealtimes. Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,24,35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supported by staff who are competent and qualified. People are safeguarded by the homes recruitment and training procedures. EVIDENCE: Staff files did not contain all relevant recruitment documents. The manager assured us that that thorough pre-employment checks are carried out. He stated that most documents are held at the regional office. However, evidence Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 22 that these procedures have been followed needs to be provided. Staff also told us that all these recruitment procedures had taken place. The manager and staff told us that suitable inductions to their work are conducted for staff and a regular program of training is in place. We were shown a suitable training program that is provided by Re-Think. Two staff told us they were bank staff and had been on numerous health and safety courses. They said it was quite normal for everyone to attend all these courses. We saw evidence on files that showed staff had attended training in fire safety, food hygiene and other health and safety courses. The manager stated that all staff are trained to National Vocational Qualification (NVQ) level 2. Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 24 37,39,42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from a well managed service. They benefit from the systems that are used for monitoring and reviewing the quality of care. The health, safety and welfare of people are promoted and protected. EVIDENCE: All of the people spoken with said they felt the home was well run and the management team and staff were always on hand for support and advice. Staff confirmed that they felt supported by the manager and senior staff and that they are approachable to discuss any issues. All of the people spoken with, stated that they felt they were consulted about day to day issues. We saw evidence of reviews, meetings and consultation carried out with individual people. We observed a system that Re-Think uses for assessing the quality of it’s services and the views of people. This is a valuable tool and is designed to reflect the outcomes for service users based around the current National Minimum Standards (NMS). A relevant policy with regards to the safe keeping of person’s personal allowances is in place and followed. The staff who spoke with the inspector, confirmed they receive regular supervision and attend regular team meetings. Staff confirmed that this is part of a supportive management style provided by the manager. All of the staff files showed us that staff have undertaken training in mandatory health and safety subjects. Staff spoken with, were aware of health and safety procedures and commented positively on the training provided. Risk assessments were observed on individual files and are in place for the building and individual people. Records for Health and Safety monitoring and the servicing of systems and appliances were inspected on this occasion and were found to be up to date. Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 X 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT Standard No Score 37 3 38 X 39 3 40 X 41 2 42 3 43 X 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Shipley Lodge Score 3 3 3 X DS0000039072.V341703.R01.S.doc Version 5.2 Page 26 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 YA41 Regulation 17 Schedule 2,4(6) Requirement Ensure the records specified in Schedule 2 and 4 paragraph 6 are copies are maintained at the home and/or made available for inspection 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. Refer to Standard Good Practice Recommendations Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 27 Shipley Lodge DS0000039072.V341703.R01.S.doc Version 5.2 Page 28 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 Lodge DS0000039072.V341703.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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