CARE HOMES FOR OLDER PEOPLE
Stacey Street Nursing Home 1 Stacey Street London N7 7JQ Lead Inspector
Beverley Brewer Announced 12 July 2005 10:00am
th 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Stacey Street Nursing Home G58 s10327 Stacey v198687 120705 Stage 2.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Stacey Street Nursing Home Address 1 Stacey Street London N7 7JQ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7700 2400 enquiries@mosaichomes.co.uk Mosaic Homes Margaret Elizabeth Ford Care Home 30 Category(ies) of MD Mental Disorder (0), MD (E) Mental Disorder registration, with number - over 65 (0) of places Stacey Street Nursing Home G58 s10327 Stacey v198687 120705 Stage 2.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: For the provision of Mental Nursing Care for up to 30 Adults mainly elderly, who are not required to be detained at the home under any section of the MHA. Date of last inspection 8/2/05 Brief Description of the Service: Stacey Street is a thirty bedded care home for older people with mental health problems. The home is situated in Finsbury Park on a small housing estate. Holloway Road shopping area is within ten minutes walk. The home was purpose built ten years ago. The facilities are arranged over three floors with ten service users accommodated on each of the floors. All service users have their own bedroom with wash-hand basin. Each floor has a lounge, kitchen and dining room. There are two additional smoking lounges. A pleasant garden is located at the rear of the property.Full personal care is provided. There is a Registered Mental Nurse on duty 24 hours a day. Health care needs are met by visiting professionals such as Psychiatrists, Occupational Therapists and Psychologists. Stacey Street Nursing Home G58 s10327 Stacey v198687 120705 Stage 2.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the first announced inspection within the new inspection schedule from 1st April 2005 to 31st March 2006. The inspection took 6 hours during a weekday. The majority of the time was spent speaking with the manager, service users, two relatives and members of the staff team. The remainder of time was spent examining records, touring the premises and observing the interaction between staff and service users. Comment cards were sent out with the pre-inspection material and twenty were returned. What the service does well: What has improved since the last inspection? Stacey Street Nursing Home G58 s10327 Stacey v198687 120705 Stage 2.doc Version 1.30 Page 6 Service user plans of care have been revised to include any religious or cultural needs. The quality of the recording of medication administered on behalf of service users has also improved. 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. Stacey Street Nursing Home G58 s10327 Stacey v198687 120705 Stage 2.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Stacey Street Nursing Home G58 s10327 Stacey v198687 120705 Stage 2.doc Version 1.30 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3. Standard 6 is not applicable to this service. This service has a planned admission process, which ensures that service users’ needs can be met following a full assessment. Each service user has an individual care plan. EVIDENCE: Six assessments were examined in detail. The quality of the assessment material was good. The Clifton Assessment for the elderly is used. Assessments highlighted needs and indicated the external involvement provided or required. Stacey Street Nursing Home G58 s10327 Stacey v198687 120705 Stage 2.doc Version 1.30 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10. Service users receive a high standard of health and personal care. EVIDENCE: The quality of the care plans examined was good. There was significant evidence of a multi disciplinary approach. Care plans indicate liaison with external health professionals including community mental health services, services for those with diabetes and district nurses. Staff reported that the service provided by the General Practitioner was good. Medication arrangements were found to be satisfactory. Service users and relatives stated that staff always treated them with respect. The Inspector observed staff speaking to service users in a respectful manner. All staff observed knocked on bedrooms before entering. Stacey Street Nursing Home G58 s10327 Stacey v198687 120705 Stage 2.doc Version 1.30 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15. Service users maintain contact with family and friends. Service users are helped to exercise control over their lives. Service users receive a wholesome diet. EVIDENCE: Two relatives and five service users were interviewed in respect of the above standards. Relatives said that they were always made welcome and could have a meal with their loved one if desired. Social, cultural and recreational needs were reflected in the individual plans of care. Staff were observed speaking with service users to encourage and enable them to make choices. Stacey Street Nursing Home G58 s10327 Stacey v198687 120705 Stage 2.doc Version 1.30 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The home has a satisfactory complaint’s process with evidence that service users feel that their views are listened to and acted on. An appropriate adult protection procedure is in place. EVIDENCE: The home has a satisfactory complaints procedure, which is known by both staff and service users. A copy is incorporated into the service user guide. There is a system in place to record and monitor complaints. The home has a whistle blowing procedure and an adult protection procedure. Stacey Street Nursing Home G58 s10327 Stacey v198687 120705 Stage 2.doc Version 1.30 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 26 Stacey Street is generally maintained to a high standard and offers good quality accommodation. The home is clean and pleasantly furnished. EVIDENCE: Stacey Street is generally maintained to a high standard and offers good quality, homely accommodation. The home was found to be clean throughout. On the day of the inspection the seal around the kitchen sink was old and needed replacing. A new floor seal is also required in the kitchen. A requirement has been made in relation to this. Stacey Street Nursing Home G58 s10327 Stacey v198687 120705 Stage 2.doc Version 1.30 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 & 30 Recruitment practices are of a high standard, which should ensure the safety and well-being of service users. Staff training arrangements will ensure service users individual needs are met. EVIDENCE: Four staff files were examined. Copies of two references and a CRB check were available on each file. Staff are supervised on a monthly basis. A variety of training is provided and recorded on individual files. Staff confirmed that the training provided was of a good standard. Stacey Street Nursing Home G58 s10327 Stacey v198687 120705 Stage 2.doc Version 1.30 Page 14 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 & 38 The home is run in the best interests of service users. Health and safety is promoted. Confirmation is required that the remedial work identified in the gas safety report has been addressed. EVIDENCE: Quality assurance and quality monitoring systems are in place based on seeking the views of service users. Health and safety matters are well promoted. Portable appliances were tested in October 2004. Fire precautions were found to be satisfactory. A number of deficits were noted in the gas safety report. Written confirmation is required that these matters have been addressed. Stacey Street Nursing Home G58 s10327 Stacey v198687 120705 Stage 2.doc Version 1.30 Page 15 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 x x x x x x 2 STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 3 x 2 Stacey Street Nursing Home G58 s10327 Stacey v198687 120705 Stage 2.doc Version 1.30 Page 16 No 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. 2. Standard 26 38 Regulation 23(2)(b) 23 Requirement The registered person is required to replace the floor seal and the seal around the kitchen sink. The registered person is required to forward confirmation that the remedial work identified in the gas safety report has been addressed. Timescale for action 30/9/05 30/9/05 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 Good Practice Recommendations Stacey Street Nursing Home G58 s10327 Stacey v198687 120705 Stage 2.doc Version 1.30 Page 17 Commission for Social Care Inspection Centro 4 20-23 Mandela Street Camden Town London NW1 0DW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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