Care Home: Shipley Hall Nursing Home

Similar services:

• Byars Care Home
• St Marys Nursing Home
• Bramble Lodge
• Parkmanor Residential Home
• Thornham Grove
• Hunter`s Lodge
• London Road Neurological and Specialist Care Unit
• Carlton Care Home

What the care home does well People who were able to express an opinion, told us they were happy with the personal care they received and that staff gave them respect. People also said that they enjoyed the meals provided. Their comments about meals included `pretty good`, `I`ve no complaints` and `too good`. People knew how to make a complaints and said `there`s no complaints`. People also said that in general, the home is clean and tidy, comments included `can`t fault the cleanliness` and `are very strict on cleanliness`. What the care home could do better: We found that there had been poor progress on meeting the requirements of the last Inspection, within the timescales given. We will be issuing new timescales and meeting the provider to discuss the actions we require them to undertake. Random inspection report Care homes for older people Name: Address: Shipley Hall Nursing Home The Field Shipley Heanor Derbyshire DE75 7JH one star adequate service The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Helen Macukiewicz Date: 0 3 1 1 2 0 0 9 Information about the care home Name of care home: Address: Shipley Hall Nursing Home The Field Shipley Heanor Derbyshire DE75 7JH 01773764906 F/P01773764906 shipleyhall123@aol.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Shipley Hall Limited care home 30 Number of places (if applicable): Under 65 Over 65 30 old age, not falling within any other category Conditions of registration: 0 One DE(E) place for service user named in notice of proposal letter dated 09 January 2006. One MD place for the service user named in the notice of proposal letter dated 29 November 2005. Registration to include the accommodation of one named service user PH (as specified on the notice of proposal) under the category PD, not transferrable to any other service users. The Responsible Individual must submit a Manager for registration within 3 months of registration. Date of last inspection Care Homes for Older People Page 2 of 17 Brief description of the care home Shipley Hall is a care home with nursing, set in attractive parkland grounds, with a pond and gardens that attract a variety of wildlife. The home is a converted, extended building, dating from the turn of the century, and provides facilities for thirty residents. There are five day/quiet rooms, which include two conservatories overlooking the garden areas. Accommodation is provided on ground and first floors, with passenger lift and staircase access to the first floor. An additional stair-lift provides assisted access to one of the first floor bedrooms up a short flight of stairs. There are eighteen single bedrooms and six double bedrooms, all with wash hand basins. No en-suite rooms are provided, but the home has adequate provision of WC and bath/shower facilities throughout, including an assisted bath. All rooms are equipped with a call system. The nurse in charge at the time of the last Inspection told us that the current range of fees is from 375.00 GBP to 455.00 GBP per week plus top up for continuing care. A copy of an outdated Inspection report was seen in the foyer. Care Homes for Older People Page 3 of 17 What we found: The inspection was unannounced and involved a four hour visit to the site on the 3rd November 2009 at 11.30 pm. The purpose of this visit was to monitor compliance with former requirements made, both unmet from previous inspections and from the last key Inspection of this service on 13th July 2009. The focus of inspections undertaken by the Care Quality Commission (CQC) is upon outcomes for people using the service and their views of the service provided. This process considers the homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Choice of Home: We saw that people had more information about the home. We saw copies of the service user contracts in peoples bedrooms. People had their needs assessed prior to admission, but there were gaps in the basic information that was recorded about them, including social care needs. This could impact on the homes ability to provide personalised care. We also found that the moving and handling assessment form did not allow staff to identify any unpredictable behaviours that might impact on this area. This means that a potential risk area was not being fully assessed. We asked that people had a comprehensive assessment of need on admission at the time of our last Inspection visit. This is a requirement that has not been fully met within prescribed timescales. Health and Personal Care: We saw five peoples care records. We found that there had been some improvements in the way care needs were being recorded and reviewed. A system was in place whereby the acting manager audited care records and highlighted areas for improvement. However, we also found that care plans did not fully document the care required, and safety measures in place, for people whose behaviours meant they could be potentially aggressive both to staff and other people living in the home. We also found that peoples social care needs were not fully included in the main care plan and what they liked to do was not included as part of a daily plan of care. One person told us there should be a little bit more to do. We asked that people had a plan of care that clearly detailed all care needs at the time of our last two Inspection visits. This is a requirement that has not been fully met within prescribed timescales. We also found a tablet on the floor of the lounge. This meant that staff were not ensuring that people had the medication they required, and there was the possibility of another person picking up and taking the medication. Care Homes for Older People Page 4 of 17 Daily Life and Social Activities: There were still some issues that impacted on the privacy and dignity of people living in the home, although a privacy lock had been fitted to one toilet as we had requested. Shared bedrooms, where people were accommodated, did not have adequate privacy screening. One portable screen provided no privacy, and was found to be unstable. One bedroom had curtain dividers that had come off the tracks so could not be fully closed, and a third unoccupied double bedroom had no means of privacy screening. The care plans for people who were sharing rooms did not identify that they had made a choice/agreed to share. Some spare and unlabeled underwear/hosiery was stored in a bathroom. Another bathroom, currently in use by people living in the home had a list displaying peoples personal continence needs. We asked that these issues impacting on peoples privacy and dignity be addressed at the time of our last Inspection visit. This is a requirement that has not been fully met within prescribed timescales. Complaints and Protection: People had information available about how to raise concerns. We found that people who needed forms of mechanical restraint such as bed rails to keep them safe had consent from the relatives in the care file. However, this was not the case for people who had wander mats in place, which could be equally as restricting on movement around the home. We asked that forms of restraint be used only following appropriate assessment and consent to be addressed at the time of our last Inspection visit. This is a requirement that has not been fully met within prescribed timescales. Environment: New heating had been provided and some new bedroom furniture. Maintenance of the garden areas was taking place when we visited. Repairs to a roof were reported to have taken place but some water damage was still evident in a toilet used by people living in the home that needed attention. We found that two out of the three bathrooms that contained a bath had been put out of use. The remaining bath was not suitable for use by people requiring a hoist. This meant that these people only had the option of an assisted shower. The main parts of the home were cleaner than we had found them to be at the last Inspection. However, we noticed that there were still some chairs, wheelchairs and carpets that were heavily stained. We asked that all areas be kept clean and tidy at the time of our last Inspection visit. This is a requirement that has not been fully met within prescribed timescales. Staffing: Care Homes for Older People Page 5 of 17 We found that there was a training programme in place for staff and that staff had completed National Vocational Qualifications and Dementia care training. However, ancillary staff had still not received all the mandatory training that they required, in particular, COSHH and safeguarding adults. We asked that ancillary staff undertake the required mandatory training at the time of our last Inspection visit. This is a requirement that has not been met within prescribed timescales. Due to the absence of the provider and acting manager at the time of this visit, we could not access training or recruitment files and could therefore not fully assess all requirements previously made. Management: There continues to be acting management arrangements in place. The acting manager has not yet registered with us. The need to register a manager for the home was a requirement of the last 2 Inspections, that has not been met within prescribed timescales. We noted that the provider was not in day to day control of the home, but maintained weekly visits and regular communications with the acting manager. We found that there were no recorded monitoring visits made on behalf of the provider in line with the requirements of Regulation 26 (Care Homes Regulations 2001). The importance of such visits was increased in light of the amount of requirements that have been unmet since we last visited. We had not been notified as to recent incidents affecting peoples wellbeing at the home in line with Regulation 37 (Care Homes Regulations 2001). Therefore we were not aware of a possible safeguarding issue that had occurred. This matter had not been referred to the Local Authority in line with safeguarding procedures. We found that not all accidents that had occurred at the home had been recorded in the accident book. We saw that a chair in the conservatory near the dining room was obstructing a fire extinguisher, and that flammable items were being stored in a former bathroom that was not a designated storage area. What the care home does well: People who were able to express an opinion, told us they were happy with the personal care they received and that staff gave them respect. People also said that they enjoyed the meals provided. Their comments about meals included pretty good, Ive no complaints and too good. People knew how to make a complaints and said theres no complaints. People also said that in general, the home is clean and tidy, comments included cant fault the cleanliness and are very strict on cleanliness. Care Homes for Older People Page 6 of 17 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 7 of 17 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 19 and Schedule 2) All staff 31/08/2009 must have evidence of a rehabilitation of offenders and medical declaration before they commence work. Written verification from former care homes where people had worked, as to reasons why they had left that employment, must be obtained prior to employment. This was not assessed on this occasion. This is to ensure people are not exposed to unsuitable workers. 2 18 1)c)i) Ancillary staff must all 31/10/2009 undertake the mandatory training. An extended timescale of 31/12/2009 is given to meet this requirement. This is to ensure they have the required skills to keep people and themselves protected. 3 3 14 All people admitted to the home must have a comprehensive assessment 31/08/2009 Care Homes for Older People Page 8 of 17 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action of needs on admission. This must include identification of any social care needs, usual routines and lifestyle choices. An extended timescale of 31/12/2009 is given to meet this requirement. This is to ensure that no care need is overlooked and to promote individualised care. 4 7 15 1) Care records must be able 30/09/2009 to support that people or their representatives have been fully consulted about their care. This was not fully assessed on this occasion. Therefore an extended timescale of 31/12/2009 is given to meet this requirement. This is to ensure people have their rights upheld. 5 8 15(1)(2)(b) People must have a plan of care that clearly details all care needs, including social care needs and provides direction for staff as to what actions they need to take. This must be subject to regular review and updated as peoples care needs change. An extended timescale of 31/12/2009 is given to meet this requirement. 30/09/2008 Care Homes for Older People Page 9 of 17 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action This is to ensure care needs are not overlooked and people are kept safe. 6 9 13 6) All medication given must 31/08/2009 be signed for on the medication Administration record. This was not assessed on this occasion. An extended timescale of 31/12/2009 is given to meet this requirement. This is to support that people are getting the medication they require. 7 10 12 4)a) Spare underwear must 30/09/2009 be individually labeled and stored. All shared bedrooms must be provided with full privacy screening. Lists detailing individual continence needs must be removed from public display. An extended timescale of 31/12/2009 is given to meet this requirement. This is to promote the privacy and dignity of all people using the service. 8 18 13 7) Forms of restraint must 31/08/2009 only be used following appropriate consent and a fully recorded risk assessment process. This must be included in the persons care plan so it can be subject to ongoing review. Page 10 of 17 Care Homes for Older People Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action There must be ongoing recorded safety checks of bed rails. An extended timescale of 31/12/2009 is given to meet this requirement. This is to ensure people have their rights upheld and are kept safe. 9 26 23 2)d) All parts of the home 31/08/2009 must be kept clean and tidy. Cleaning of the main parts of the home must include chairs and regular floor cleaning to prevent build up of stains and food debris. An extended timescale of 31/12/2009 is given to meet this requirement. This is to enhance peoples quality of life and to reduce potential for infection control. 10 29 17 2) and schedule 4. Staff recruitment files must be kept available for inspection at all times. An extended timescale of 31/12/2009 is given to meet this requirement. This is to ensure there is evidence available to support that people are not exposed to unsuitable workers. 11 30 18 1)c)i) Ancillary staff must all 31/10/2009 Page 11 of 17 31/08/2009 Care Homes for Older People Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action undertake the mandatory training. An extended timescale of 31/12/2009 is given to meet this requirement. This is to ensure they have the required skills to keep people and themselves protected. 12 31 8 The manager must apply for registration with us. An extended timescale of 31/12/2009 is given to meet this requirement. 13 33 24 Reviews of the quality of care 30/09/2009 people receive must be effective in identifying gaps in care planning and assessment of need. An extended timescale of 31/12/2009 is given to meet this requirement. This is to ensure people receive good quality care and that deficits in the service are promptly identified and resolved. 14 37 23 2)c) There must be up to 31/08/2009 date service records kept at the home, and available for inspection, to support that all equipment is regularly checked for safety. This was not assessed on Care Homes for Older People Page 12 of 17 31/08/2008 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action this occasion. This is to ensure people are kept free from hazards to their safety. Care Homes for Older People Page 13 of 17 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 The moving and handling 31/12/2009 assessment must include assessment of any unpredictable behaviours and the impact this might have on moving and handling. This is to keep people safe in the home. 2 9 13 2) Staff must ensure that people take the medications they are prescribed. This is to keep people safe in the home. 31/12/2009 3 33 26 Monthly monitoring visits must be maintained and recorded by the provider consistent with this regulation. This is to ensure standards of care are monitored by the provider. 31/12/2009 4 38 37 All incidents which adversely 31/12/2009 affects the well being of people in the home must be reported to us in line with Page 14 of 17 Care Homes for Older People Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action this regulation. This is to ensure people are being kept safe at the home. 5 38 17 1a) and Schedule 3. All accidents affecting peoples wellbeing must be recorded in the accident record. This is to ensure that people are being kept safe at the home. 6 38 13 6) Safeguarding procedures must be followed where incidents affecting peoples well being occur. This is to ensure people are kept safe at the home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 31/12/2009 31/12/2009 1 1 The Statement of Purpose should be amended to reflect the fact there is no bathing facility for people requiring a hoist. This is to ensure people have the correct information on which to base their choice of home. The ceiling in the first floor toilet where water damage has occurred should be repaired and redecorated. This is to ensure people have pleasant, well maintained surroundings to live in. Facilities should be provided so that people with higher levels of need can have the option of a bath or shower. Advice should be sought from the fire officer about the storage of flammable items in the bathroom and about access to the fire extinguisher in the conservatory. Page 15 of 17 2 19 3 4 19 38 Care Homes for Older People Care Homes for Older People Page 16 of 17 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 17 of 17 - 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!