Inspection on 04/10/05 for Shipley Lodge

This inspection was carried out on 4th October 2005.

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 16 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 26/06/06

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 ADULTS 18-65 Shipley Lodge 94 Derby Road Heanor Derbyshire DE5 7QL Lead Inspector Bridgette Hill Unannounced Inspection 4th October 2005 09:45 Shipley Lodge DS0000039072.V250929.R01.S.doc Version 5.0 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.V250929.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V250929.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Shipley Lodge Address 94 Derby Road Heanor Derbyshire DE5 7QL 01773 535212 01773 535212 shipleylodge@rethink.org 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) Rethink Debbie Jayne Fenwick Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Shipley Lodge DS0000039072.V250929.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Conditions of Registration Age range of residents - 18 to 65 years With written agreement of the NCSC, 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 21st April 2005 Date of last inspection Brief Description of the Service: Shipley Lodge is 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 to 65 years, who experience enduring mental health problems. Residents have opportunities to take part in daily living and social activities, and have a more independent lifestyle. Shipley Lodge DS0000039072.V250929.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced one which took place over 3 1/2 hours. During the inspection 2 staff members, 1 visiting professional and 4 residents were spoken with. Various records including care planning records were examined the findings are recorded in the body of this report. Some records relating to previous requirements were not available at this visit as the Manager was not on duty and records were held securely. Where previous requirements have not been checked they remain listed as part of this report. This report should be read alongside the inspection report dated 21st April 2005 where many of the standards that are required to be assessed each inspection year were examined. The lead inspector was accompanied on this visit by a second inspector who was on induction. What the service does well: What has improved since the last inspection? What they could do better: Many of the requirements and recommendations listed from the visit on 21st April 2005 remain outstanding with given timescales not being met. A system must be implemented to ensure action plans are implemented. Shipley Lodge DS0000039072.V250929.R01.S.doc Version 5.0 Page 6 The environment continues to need ongoing maintenance. Some steps have been taken towards organising works this little evidence of actual completion was seen. 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.V250929.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shipley Lodge DS0000039072.V250929.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4 The admission process to the home is undertaken on an individual basis and ensures that the needs of the service user can be met at the home. EVIDENCE: Care files examined confirmed that pre admission assessments were completed by staff from the home and information was gathered from other healthcare professionals involved in the placement process. One service user spoken confirmed they had been gradually introduced to the home and visited on a number of occasions. Records also confirmed a trial period of 4 weeks was arranged prior to confirming full admission. The previous recommendation regarding the ‘licence’ agreement was discussed. Staff on duty stated that this had not yet been improved into a user friendly format. Shipley Lodge DS0000039072.V250929.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,8,9, The content of care plans was excellently written where available but in need of expansion to ensure assessed risks were considered and social needs identified to ensure service users needs will be met. EVIDENCE: A sample of three service users care files were examined. As has been identified at previous inspections there well considered and detailed care plans for medical needs supported giving good detail regarding care delivery. Care plans examined did not detail the service users assessed social needs nor how these were to be met. Where care plans were in place these included regular review dates. Risk assessment formats were available but in all files were only partially completed and were not being reviewed. There were some identified risks for example challenging behaviours which were not supported by a plan of care as to how staff were to handle these situations. Shipley Lodge DS0000039072.V250929.R01.S.doc Version 5.0 Page 10 Some care plans had been signed by service users to confirm they had been consulted and included in the care planning process but this was not consistently being completed. This is an outstanding requirement from previous inspections. A book was available which recorded service users meeting. It was evident that a range of issues were discussed and these meetings were generally well attended. An advocacy service was available and some service users did choose to use this. Service users had care plans in place regarding their finances detailing abilities and any assistance required. Shipley Lodge DS0000039072.V250929.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14,15 Service users were being actively involved in activities of daily living and social/leisure activities but records demonstrating that these formed part of an assessed needs based care plan were not available. EVIDENCE: Service users spoken to said they were offered activities. A monthly cultural night was held this was sometimes held in the home at other times meals out were enjoyed. A structured programme for each service user was displayed in the staff office. This included activities of daily living such as laundry and tidying and some day service activities outside of the home. The service user meetings confirmed that service users had been consulted regarding a choice of holiday and this was planned. Family contact varied for each service user. It was noted in the service users minutes that some friends and families had attended the homes third birthday celebrations. Shipley Lodge DS0000039072.V250929.R01.S.doc Version 5.0 Page 12 One visiting professional said that they felt service users were offered appropriate activities. Shipley Lodge DS0000039072.V250929.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. 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. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 (previous requirements only assessed) The previous requirement relating to medications storage has been met. Staff training on the storage and handling of medications has begun but is not completed. EVIDENCE: Previous requirements relating to the administration and storage of medications were checked. At this visit all medications were being stored in the original packaging as dispensed from the supplying pharmacy. It was observed that on medication administration records there were a number of handwritten amendments. Discussions with the Deputy Manager were held and an explanation put forward that these changes had been made since the last medications order had been sent. Shipley Lodge DS0000039072.V250929.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Staff required further training regarding Protection of vulnerable adults procedures to ensure appropriate actions were taken if any allegation of abuse was to be made. EVIDENCE: The deputy Manager said that staff had not received formal Protection of vulnerable adults list training or training in the referral procedure for any concerns relating to alleged abuse and the process that is initiated following referral. Staff spoken to appeared to be unclear about the course of action to be taken when concerns had been raised following allegations being made. Shipley Lodge DS0000039072.V250929.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 25,26,28 The general environment of the home is beginning to show signs of wear and investment is required to ensure it is a well maintained environment suitable to meet the needs of service users. EVIDENCE: The following environmental issues are outstanding from the previous inspection of 21st April 2005 • • • • Carpets in corridors were badly stained in places. A carpet in a bedroom was badly stained and required replacement. The sofa’s in one lounge were showing signs of wear. The base of one drawer in a residents room was broken and unusable Some quotes for carpets had been sought. Replacement chairs were said to be on order and due to arrive at any time. The corridor was being prepared for redecoration at the time of the visit and one service users bedroom had been redecorated in a colour of their choice. Shipley Lodge DS0000039072.V250929.R01.S.doc Version 5.0 Page 16 At this visit the following was observed • • • The flooring in one service users kitchen was split. The drawer of one unit in the service users kitchen was missing. The smoke extraction units in the conservatories were very dusty and seemingly not very effective. The main kitchen flooring had been replaced since the last inspection. Service users spoken to said the room converted to a gym was now rarely used and it is recommended that the use of this room is reviewed to ensure space is used in the best interests of the service users. Two service users bedrooms were viewed with their permission. These were personalised and found to be clean. Shipley Lodge DS0000039072.V250929.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 Staffing levels were being maintained and service users were cared by staff who were knowledgeable regarding the service users needs. EVIDENCE: Staffing levels were being maintained at 4 staff per day shift of which the aim was to include 2 qualified nurses within this. At night 2 staff including 1 qualified nurse. There was continuous use of agency staff to cover shifts but these tended to be the same staff who knew the service users. Some sickness was noted on the rota but these shifts were being covered by other staff. There were continued problems reported by the Deputy Manager regarding the recruitment of evening domestic staff and care staff were said to be undertaking some domestic duties to supplement this deficit. This is an outstanding requirement from previous inspections that domestic staff must be employed in sufficient numbers. One service user said there was always plenty of staff of around. One visiting professional said staff were knowledgeable regarding the service users and they had no concerns. Staff training and supervision records were not available at this visit therefore these standards have not been assessed. Where requirement are listed in relation to these they remain listed as part of this report and are identified as not being met. Shipley Lodge DS0000039072.V250929.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. 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 home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,43 The is a stable management team at the home but work must be undertaken to ensure that the findings of the inspection are addressed and the home can meet the standards required. EVIDENCE: A service user survey had been completed on the last inspection. No results had yet been collated or published from the findings of this. This is an outstanding requirement from previous inspections Actions to address identified requirements and recommendations have not been implemented and this has a direct impact on some service users. The Deputy manger said that the Manager had not yet completed a managerial qualification but was in the process of doing so. A valid public liability certificate was displayed. Records for establishing financial liability were not requested at this visit. Shipley Lodge DS0000039072.V250929.R01.S.doc Version 5.0 Page 19 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. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 3 x Standard No 22 23 Score x 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 x 2 x Standard No 24 25 26 27 28 29 30 STAFFING Score x 2 2 x 2 x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 2 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score x 2 3 2 x 2 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Shipley Lodge Score x x 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 2 x x x 3 DS0000039072.V250929.R01.S.doc Version 5.0 Page 20 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 YA14YA6 Regulation 15(1) Requirement Care plans must record and detail how social/leisure needs are to be met Previous timescales 30/12/04 timescale 30/06/05 from last inspection – This is has not been met Where residents have the capacity to become involved in the care planning process they must be given the choice to do so. Records must be had to demonstrate this has been considered and offered. Previous timescale 30/07/05 Risk assessments must be completed and any identified actions taken to minmimise identified risks to the service user or others All staff with the responsibility for administering medications must receive acredited medication training Previous timescale not met Shipley Lodge DS0000039072.V250929.R01.S.doc Version 5.0 Page 21 Timescale for action 30/11/05 2 YA6 15(1) 30/11/05 3 YA9 15 30/11/05 4 YA20 13 (2)17 (1) Sched 3 30/11/05 30/08/05 5 YA23 13(6)18(1)(c) Staff must receive training on the protection of vulnerable adults list and a policy must be in place for a referral procedure for this 30/11/05 6 YA23 23(2)(b) Previous timescales 30/12/04 30/06/05 from last inspection – This is has not been met A replacement programme 31/12/05 must be inplace to ensure furnishings and flooring are promptly replaced when they become worn. Details contained in the body of this report Previous timescale not met 30/06/05 Broken furniture in residents bedrooms must be replaced Previous timescale not met 30/07/05 Residents must be given access to keys and lockable facilities where they wish this and it is assessed as appropriate Previous timescale not met 30/06/05 Staff must be employed in adequate numbers to ensure standards of cleanliness are maintained. Previous timescale not met 30/06/05 All required checks as described in Schedule 2 of the care homes regulations must be completed before prospective employees are allowed to commence employment DS0000039072.V250929.R01.S.doc 7 YA26 16(2)(c) 30/10/05 8 YA26 16(2)(c) 30/10/05 9 YA32 18(1)(a) 23(2)(d) 30/11/05 10 YA34 19 Schedule 2 30/09/03 Shipley Lodge Version 5.0 Page 22 11 YA34 19 Schedule 2 12 YA34 19 Schedule 2 13 YA36 18(2) 14 15 YA37 YA39 8 35 Previous requirement - not able to check this at this visit as records not available Copies of application forms for staff must be available in the home. Previous requirement - not able to check this at this visit as records not available Disclosure information on Criminal Records Bureau (CRB) checks must be handled in accordance with the Criminal Records Bureau code of conduct Previous requirement - not able to check this at this visit as records not available Records must be in place to demonstrate supervision and support is offered to all staff working in the home on a regular basis Previous requirement - not able to check this at this visit as records not available The registered manager must achieve an NVQ level 4 or equivalent Quality assurance systems must be put in place to regularly ascertain the views of residents, visitiors, staff and visiting healthcare professionals 30/09/03 30/11/03 30/06/05 30/12/05 30/12/05 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 DS0000039072.V250929.R01.S.doc Version 5.0 Page 23 Shipley Lodge 2 3 YA28 YA34 understandable for the resident group. The use of the gym should be reviewed as service users say this is now rarely used and the spce could be better utiised if this is so The home should have a copy of the code of conduct guidance from the CRB regarding the handling of disclosure informationThe home should have its own policy regarding the handling of disclosure information which adheres to the CRB code of conduct document Shipley Lodge DS0000039072.V250929.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shipley Lodge DS0000039072.V250929.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!