Inspection on 26/06/06 for Shipley Lodge

This inspection was carried out on 26th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 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 22/05/07

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 DE5 7QL Lead Inspector Janet Morrow Key Unannounced Inspection 26th June 2006 10:00 Shipley Lodge DS0000039072.V300965.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.V300965.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.V300965.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shipley Lodge Address 94 Derby Road Heanor Derbyshire DE5 7QL 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) VACANT Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Shipley Lodge DS0000039072.V300965.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Conditions of Registration Age range of residents - 18 to 65 years With written agreement of the CSCI, residents over the age of 65 who meet the registration category, may be accommodated. Where residents over the age of 65 are residing in the home, consideration is given to the Care Homes for Older People National Minimum Standards The Conditions of Registration to be reviewed annually 4th October 2005 Date of last inspection Brief Description of the Service: Shipley Lodge is a purpose built care home. It is situated in the 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. Residents have opportunities to take part in daily living and social activities, and have a more independent lifestyle. Shipley Lodge DS0000039072.V300965.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and took place over 6 hours. Care records and staff records were examined. Three members of staff, three residents and the acting manager were spoken with. One visiting professional was contacted by telephone following the inspection. A tour of the building took place. What the service does well: What has improved since the last inspection? Social and leisure needs were being addressed on care plans and evidence of service users involvement in their care plan was available. Identified risks were being addressed and there were also assessments available for the holding of keys to bedrooms and lockable facilities in bedrooms. Information on the Protection of Vulnerable Adults list had been made available and staff had received in-house training on adult protection from the provider organisation, Rethink. Some refurbishment had taken place, such as the provision of new seating in one lounge and a new carpet in the entrance hall and some damaged bedroom furniture had been repaired. A review of the gym facility had taken place and service users had requested a quiet room instead, which was now in operation. There were sufficient domestic staff employed to maintain the home’s cleanliness. Staff application forms were available in recruitment information and the home had obtained detailed information on how to deal with Criminal Record Bureau disclosures. Shipley Lodge DS0000039072.V300965.R01.S.doc Version 5.2 Page 6 Staff supervision records were available. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shipley Lodge DS0000039072.V300965.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.V300965.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 and 5 (YA), 2, 3, 4 and 5 (OP) There was sufficient admission information available to ensure that the home was suitable and can meet the needs of service users. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Two care files were examined and assessment information was in place that showed that the home was able to meet identified needs. One service user confirmed that several visits had taken place before their admission to help them familiarise themselves with the home and assess its suitability. One service user spoken with praised the home and said their needs had been well met and they had improved as a result of the help and care received. A visiting professional contacted following the inspection stated that the home had met the needs of the service users they were involved with. Shipley Lodge DS0000039072.V300965.R01.S.doc Version 5.2 Page 9 Some additional assessment information in relation to nutrition and physical health needs would enhance the care offered, particularly in relation to older service users. The terms and conditions of residence, or ‘licence agreement’, were not examined but the manager stated that there had been no change to them. Shipley Lodge DS0000039072.V300965.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10 (YA) 7, 14 33 and 37 (OP) Individual care plans ensure that consistent patterns of support are given and that confidentiality is maintained. Decision making processes ensured that service users contributed to the running of the home, which enhanced their confidence and skills. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Two care files were examined and showed that a comprehensive care plan was in place that demonstrated how individual needs would be met. Risk assessments were available in individual care files that showed how identified risks were minimised. However, there were no moving and handling risk assessments for any service users and no nutritional assessment on either of Shipley Lodge DS0000039072.V300965.R01.S.doc Version 5.2 Page 11 the files examined. This is particularly relevant to meet the standards for older people. Those service users spoken with confirmed that they were aware of their care plan and a signature on the care plan evidenced this. They also stated that confidences were respected. Records were stored securely. There was evidence from general observation and discussion with service users that they were involved in decisions about their life and able to make decisions, with assistance, as required. Discussion with staff and service users, and examination of satisfaction surveys, showed that service users were able to participate in decisions in the running of the home. For example, the use of one communal room had changed following a service users’ meeting and one service user spoken with was able to give an example of their suggestion being acted on. Shipley Lodge DS0000039072.V300965.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 (YA) 10, 12, 13 and 15 (OP) Service users quality of life was enhanced by well managed meals, contacts with the community and activities. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Shipley Lodge DS0000039072.V300965.R01.S.doc Version 5.2 Page 13 EVIDENCE: Those service users spoken with confirmed that they were able to have their own routines and have visitors or go out into the community when they wished. This was directly observed during the inspection. Religious activities were attended as service users wished and four service users had been on a visit abroad to Paris. Outings to places of interest took place on monthly basis. The serving of the lunchtime meal was observed and a meal was sampled. All service users spoken with during the lunchtime period stated that they enjoyed the food and a wide choice was on offer. The menus showed that food was nutritious and staff and service users confirmed that meals were also taken out at restaurants and that a monthly ‘cultural’ evening took place where different dishes from around the world were sampled. These had included meals from Africa, China, and the continent. A photographic record of these occasions was maintained and questionnaires completed about the events contained very positive comments from service users, such as the food was ‘cooked so well and so tasty’. Service users spoken with also confirmed that they had the opportunity to join in cooking sessions at the home if they wished. Shipley Lodge DS0000039072.V300965.R01.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 (YA) 8, 9 and 10 (OP) Residents’ health and personal care needs are well managed, which ensures that good health is maintained. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Two care files were examined and showed that access to health professionals was made available. There were records available that showed visits to dentists, opticians and General Practitioners took place. Those service users interviewed also confirmed this and stated that the staff at the home helped them to sort out specific health needs. Personal support was offered sensitively and service users interviewed stated that they found staff helpful. One service user was very pleased with the help received and stated that the staff ‘didn’t give up on me’. Shipley Lodge DS0000039072.V300965.R01.S.doc Version 5.2 Page 15 A visiting professional contacted by telephone following the inspection commented favourably on the care one service user had received, stating that specialist needs were ’sensitively managed’. Two service users’ medication administration record (MAR) charts were examined. Recording on the MAR charts corresponded with the dispensing system and there were two signatures on the handwritten charts. A copy of the Royal Pharmaceutical Society Guidelines was supplied during the inspection visit. There was secure storage for controlled drugs. There were no controlled drugs in storage at the time of the inspection, although Temazepam was stored under controlled conditions. The medicine refrigerator temperatures were recorded regularly, although the refrigerator was empty at the time of the inspection. Temperatures were recorded as being within safe limits. Shipley Lodge DS0000039072.V300965.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 (YA) 16 and 18 (OP) A clear complaints procedure ensured that complaints were dealt with objectively. Adult protection procedures were robust and protected service users. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Examination of the complaints record showed that there had been no complaints at the home since the last inspection in October 2005. There had also been no complaints received at the office of the Commission for Social Care Inspection. The complaints procedure stated that complaints would be dealt with in twenty-eight days. Derby and Derbyshire Local Authority Social Services adult protection procedures were in place and the provider organisation, Rethink, had provided adult protection training for staff. There had been one allegation of potential abuse notified to the Commission for Social Care Inspection since the last inspection in October 2005 and this was still under investigation using the appropriate procedures. The acting manager stated that a second allegation had also been dealt with through the appropriate procedures. Shipley Lodge DS0000039072.V300965.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 30 (YA) 19, 20, 21, 23, 24, 25 and 26 (OP) The home was generally well maintained although further refurbishment would enhance the quality and comfort of the accommodation. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home was generally well maintained and furnishings and fittings were of good quality and bedrooms were personalised. The manager stated that new seating was due to be purchased for one lounge and that a number of areas had been refurbished including new carpets in the entrance hallway and new Shipley Lodge DS0000039072.V300965.R01.S.doc Version 5.2 Page 18 seating in one lounge. However, there were still areas in corridors and lounges and a specific bedroom where carpets were stained and showing signs of wear and tear, as highlighted at the last inspection in October 2005. There was also a large area of damaged paintwork in one identified bedroom. A visiting professional contacted by telephone after the inspection also commented on a specific bedroom needing attention. These issues should be addressed as a matter of priority. Not all bedrooms had all the items detailed in Standard 26 such as a table and two comfortable chairs. There was also no written record to state why certain items had not been supplied. However, those residents interviewed stated that they were happy with their rooms and the furnishings and fittings in them, although one resident requested a more comfortable chair. The kitchen was clean and tidy and staff spoken with stated that all equipment was in good working order. There had been no changes to individual or communal room sizes since the last inspection in October 2005 and these met the recommendations of the National Minimum Standards. The laundry was neat and tidy. There was a named nurse for infection control. Staff spoken with stated that there was no specific training on infection control although this was covered in general health and safety training. The communal areas of the home were clean, tidy and odour free. Shipley Lodge DS0000039072.V300965.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36 (YA) 27, 28, 29 and 30 (OP) There were sufficient, well trained and qualified staff to ensure that service users’ needs were met. Recruitment procedures needed improvement to ensure service users were fully protected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The staff rotas for the weeks beginning 19th and 26th June 2006 were examined. Staffing levels were being maintained at four staff per day shift, of which two were qualified nurses and at night there were two staff including one qualified nurse. Previous concerns about the level of domestic staff were resolved. The acting manager stated that there had been no issues regarding cleanliness of the Shipley Lodge DS0000039072.V300965.R01.S.doc Version 5.2 Page 20 home. There was a current vacancy for a weekend cleaner but the manager stated other domestic staff covered one shift at the weekend. Staff training and supervision records were available and showed that mandatory health and safety training was undertaken, with the exception of moving and handling training, as well as training applicable to the role such as personal safety and palliative care. There were some additional training needs identified in discussion with staff, notably managing challenging behaviour and moving and handling procedures. Two staff files were examined and some items of information required by Schedule 2 of the Care Homes Regulations 2001 were missing. For example, one file had no evidence of a criminal record bureau check, qualification or identity. The personnel department of the provider organisation, Rethink, was contacted following the inspection and confirmed that a Criminal Record Bureau check had not been obtained for the identified staff member. This must be rectified as a matter of urgency. Shipley Lodge DS0000039072.V300965.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 (YA) 31, 33, 37 and 38 (OP) The home was well run although further improvements in health and safety and in quality assurance would ensure that the home was consistently run in service users’ best interests. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Shipley Lodge DS0000039072.V300965.R01.S.doc Version 5.2 Page 22 EVIDENCE: A new manager had been appointed and was yet to apply for registration with the Commission for Social Care Inspection. There was no quality assurance plan for the home available and although service user satisfaction surveys were undertaken and their views gathered on meals and food, there was no record of any action taken to address issues raised. Those surveys seen were generally satisfactory. Records were stored securely. There were omissions from the information held in staff and care files as identified earlier in the report, which meant that the requirements of Schedules 1 – 4 of the Care Homes Regulations 2001 were not fully met. Staff interviewed confirmed that health and safety training was undertaken in food hygiene, infection control and fire safety and this was confirmed in the training records seen. However, there was no moving and handling training being undertaken. This must be rectified to meet both the standards for younger adults and older people. Records seen showed that maintenance checks were undertaken regularly; for example fire equipment had been checked by an external company in July 2005, fire alarms were tested on a fortnightly basis and smoke alarms weekly. Water temperatures and tests for Legionella had been undertaken in May 2006. Shipley Lodge DS0000039072.V300965.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 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 2 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT Standard No Score 37 2 38 X 39 2 40 X 41 2 42 2 43 X 2 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Shipley Lodge Score 3 3 3 X DS0000039072.V300965.R01.S.doc Version 5.2 Page 24 YES Are there any outstanding requirements from the last inspection? 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 YA34 Regulation 19 (1) (b) Schd 2 Requirement All required checks as described in Schedule 2 of the Care Homes Regulations 2001 must be completed before prospective employees are allowed to commence employment. This is a previous requirement outstanding from 2003. The manager must apply for registration with the Commission for Social Care Inspection. Quality assurance systems must be put in place to regularly ascertain the views of residents, visitors, staff and visiting healthcare professionals. Previous timescale of 30.12.05 not met. Timescale extended. A replacement programme must be in place to ensure furnishings and flooring are promptly replaced when they become worn. Details contained in the body of this report DS0000039072.V300965.R01.S.doc Timescale for action 24/07/06 2. YA37 9 (2) 01/12/06 3. YA39 24 (1) 01/12/06 4. YA24 23 (2) (b) 01/09/06 Shipley Lodge Version 5.2 Page 25 5. YA6 & YA19 12 (1) (a) 6. YA6 & YA42 13 (5) 7. YA41 17 (1) Previous timescales of 30/06/05 and 31/12/05 not met. The home must be conducted so 01/09/06 as to promote and make proper provision for the health and welfare of service users. There must be suitable 01/12/06 arrangements to provide a safe system for moving and handling service users. The records specified in Schedule 01/09/06 3 of the Care Homes Regulations 2001 must be available in service users files. Shipley Lodge DS0000039072.V300965.R01.S.doc Version 5.2 Page 26 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 YA5 Good Practice Recommendations The service users ‘licence agreement’ should be modified to make the language more user friendly and understandable for the resident group. This is a previous recommendation and has not yet been addressed. Care plans should contain a nutritional assessment and action to address nutritional needs. Moving and handling assessments should be in place on all care files. Two comfortable chairs should be provided in service users’ bedrooms. Reasons not to provide these items should be recorded. Staff should receive training in moving and handling procedures. All staff files should contain the information specified in Schedule 2 of the Care Homes Regulations 2001 such as a Criminal Record Bureau check, identity information and proof of qualifications. Service users’ care files must contain all the information required by Schedule 3 of the Care Homes Regulations 2001, particularly in relation to nutrition. 2. 3. 4. 5. 6. YA19 YA6 YA26 YA35 & YA42 YA34 7. YA41 Shipley Lodge DS0000039072.V300965.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Shipley Lodge DS0000039072.V300965.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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