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Inspection on 01/11/05 for Stapely Residential & Nursing Home

Also see our care home review for Stapely Residential & Nursing Home for more information

This inspection was carried out on 1st November 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Stapely Nursing Home provides care for Jewish Older Persons it has a relaxed environment. Residents stated they enjoy living at Stapely Nursing Home. Many of the staff hold an NVQ Care Certificate. Record keeping is well organised. The administration of medication is properly organised and recorded.

What has improved since the last inspection?

Staff recruitment checks are more robust and all staff have been CRB (Criminal Records Bureau) and POVA (Protection of Vulnerable Adults) checked. Staff have been recruited so to eliminate the usage of agency ensuring continuity of care for residents

What the care home could do better:

Supervision sessions need to be arranged for all staff to ensure they receive the 6 sessions per year as determined in the Care Standards Act. A new carpet is needed in the front lounge as the present one is heavily stained. The Home Manager is not totally supernumery this is needed to ensure the smooth running of the home is maintained.

CARE HOMES FOR OLDER PEOPLE Stapely Nursing North Mossley Hill Road Liverpool Merseyside L18 8BR Lead Inspector Andrea Morris Unannounced Inspection 1st November 2005 08:30 X10015.doc Version 1.40 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 Stapely Nursing DS0000025179.V263691.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 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. Stapely Nursing DS0000025179.V263691.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Stapely Nursing Address North Mossley Hill Road Liverpool Merseyside L18 8BR 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) 0151 724 3260 Trustees for the time being of Stapely Hospital Angela Denise Lang Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Stapely Nursing DS0000025179.V263691.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th January 2005 Brief Description of the Service: Stapely Nursing Home is a registered nursing home for the Jewish Community situated within the residential area of Mossley Hill in Liverpool. The home is set in a large listed building and is situated within mature gardens. The home is able to provide 33 single rooms, some with en suite facilities. The home has a car park at the front and well-maintained gardens at the rear. The care home is situated near to shops and other community amenities. Stapely Nursing DS0000025179.V263691.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector spoke to the Home Manager, staff and residents during the visit. A tour of the home was conducted, a range of documents were examined including residents files, staff recruitment files, fire safety records including certificates relating to Health & Safety (held in an additional file), policy and procedure file and the complaints and accident books. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Stapely Nursing DS0000025179.V263691.R01.S.doc Version 5.0 Page 6 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 Outcomes Statutory Requirements Identified During the Inspection Stapely Nursing DS0000025179.V263691.R01.S.doc Version 5.0 Page 7 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 the following standard(s): 1, 2, 3, 4, 5 All residents are assessed prior to admission, this ensures that care needs can be met. EVIDENCE: The homes Statement of Purpose has been up dated accordingly. The Service User guide is available for all residents; copies are available upon request. Prior to admission to the home, the Home Manager or designated nurse assesses resident’s needs, to ensure the needs of the individual can be met. On examination of residents care plans, and in discussion with residents and families it was evident that needs of the resident was well documented. Residents felt they were able to contribute to their care plans where able. Care plans were clear and concise and reviewed on an at least a monthly basis. Trial visits for new residents is offered, new residents can visit the home prior to admission and spend a few hours with the other residents and staff. Families are also encouraged to visit. Stapely Nursing DS0000025179.V263691.R01.S.doc Version 5.0 Page 8 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 the following standard(s): 7, 8, 9, 10, 11 All residents have an individualised care plan, which are reviewed monthly to ensure all needs are being met. Medication is well organised, protecting the health and welfare of residents. EVIDENCE: Each resident has an individual care plan, which is well documented and clearly identifies all aspects of health, social, and personal care needs. Care plans are reviewed monthly and those concerning tissue viability are reviewed on an individual basis. The daily entries are on occasions not sufficient, they need to reflect the daily care of the individual resident, ‘ all care maintained’ is not a true reflection of daily activities. From the care files viewed at the time of the inspection it was evident that where necessary other health care professionals input was being obtained particularly in relation to tissue viability, this evidence was well documented in individual care plans. During the inspection several residents medication charts were examined, it was found that medication was well managed in the home. Residents Mar Stapely Nursing DS0000025179.V263691.R01.S.doc Version 5.0 Page 9 sheets were fully completed, all medication returned to the pharmacy was signed for by the home and the person collecting the medication. Residents stated they can if they wish choose to see their visitors in their rooms ensuring their privacy is maintained. The home has its own mortuary, allowing for Jewish death rites to be practiced appropriately. Along side the current policy the home has an information sheet that was viewed ensuring all persons working in the home are aware of the cultural practices within the Jewish faith. The Home Manager identified that all the Homes policies and procedures were in need of up dating and a process to implement this has begun. The completion date is planned for December 2005. Stapely Nursing DS0000025179.V263691.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 14, 15 Social activities are well organised, and involve community contact. are well balanced and comply with Jewish Kosher requirements. EVIDENCE: The home has an activities programme that is displayed on the walls in communal areas. The care assistants and physiotherapist deliver the programme. A separate file is kept as evidence of all activities that have been carried out in the home. Staff record in individual care plans when residents participate in activities. Several residents said they liked to go out shopping, staff accompanied the outing. The home has since the last inspection purchased a mini bus; the home has had several outings, which residents stated they had enjoyed. The home has its own synagogue, which hold monthly services. A local social club is available for residents to visit if they wish. Visiting time is an open policy. All meals are Kosher the chef receives 2-3 weekly visits from the community to assist in maintaining kosher practices. The meals are on a four weekly rota; they appeared to be well balanced. Residents confirmed that the meals were appetising and if they wanted a change from the menu that was addressed. All documentation was clear and easy to read. The midday meal was observed being served; this was carried out in an orderly and unhurried manner. Stapely Nursing DS0000025179.V263691.R01.S.doc Version 5.0 Page 11 Meals 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 the following standard(s): 16, 17, 18 Complaints received are documented well; residents and relatives can be assured they will be listened too. The introduction of Adult Protection training ensures the residents are protected against abuse. EVIDENCE: The home has a clear and concise complaints system in operation. It states how to make a complaint and details of how to complain to the Commission for Social Care Inspection. There have been no complaints made to the Commission for Social Care Inspection since the last inspection. All complaints made to the home are recorded in a book and finds/outcomes are recorded there also. If residents exercise their right to vote they are assisted to the local polling station or they can use the postal vote system. The current policies and procedures are currently under review. The home has a current policy on Adult Protection; the manager has recently attended an external training session, which she is now cascading to all staff. Staff files were reviewed during the inspection and there was evidence to support that all staff employed have had CRB (Criminal Records Bureau) checks and POVA (Protection of Vulnerable Adults) checks completed. Stapely Nursing DS0000025179.V263691.R01.S.doc Version 5.0 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 the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 Ongoing re-decoration in the home is evident, however the heavily stained lounge carpet does not provide a pleasant and hygienic environment. EVIDENCE: Since the last inspection the main corridor has been decorated and there is an ongoing re-decoration programme for individual rooms. Residents’ rooms were found to be personalised. There was no evidence of any malodours within the home. However, the front lounge carpet was found to be very badly stained and is in need of replacement. The home manager stated that a quote had been requested and the home was waiting for that to be sent. Residents if appropriate are issued with appropriate equipment i.e. air mattresses. These are maintained appropriately Stapely Nursing DS0000025179.V263691.R01.S.doc Version 5.0 Page 13 The home has assisted baths and a walk-in shower to ensure residents safety is maintained. The home has a physiotherapist to assist with resident assessment of need. All service contact certificates were in date and valid. Stapely Nursing DS0000025179.V263691.R01.S.doc Version 5.0 Page 14 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The recruitment procedure has improved and all staff have been CRB (Criminal Records Bureau) checked this ensures residents in the home are protected from abuse. Specialist training is needed to ensure residents with specialist needs have their specific needs met. EVIDENCE: The home currently is not requiring any agency staff as they have recently recruited additional care staff. The home has an adequate recruitment policy; many staff have been with the home for many years. Training for staff is being sourced externally but being held in the home. Evidence was seen that staff had attended mandatory training and there is currently a rolling monthly training programme. The induction programme has been amended since the last inspection to accommodate induction on Whistle blowing, Privacy & Dignity and Confidentiality policy training. The home manager has stated that there is also a new induction programme that is going to be introduced by December 2005. There is no specialist training sessions planned e.g. Dementia Care. Stapely Nursing DS0000025179.V263691.R01.S.doc Version 5.0 Page 15 There is a large proportion of care staff that has gained a NVQ certificate in Care. There are currently 3 members of staff waiting to commence their training in the near future. Stapely Nursing DS0000025179.V263691.R01.S.doc Version 5.0 Page 16 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 31, 33, 35 and 38 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, 36, 37, 38 The Registered manager provides guidance, leadership and direction to staff ensuring high standards of care is given to the residents. However, the manager is not in receipt of full supernumerary hours, which is necessary to ensure the smooth running of the home is maintained. EVIDENCE: The Registered Manager has completed her NVQ4 (Registered Managers Award). All persons spoken to during the inspection stated they were happy with the current manager, and with the running of the home. Staff said they felt involved and part of the team. Residents and family members stated they felt they were listened to. Visits from the Registered Person are only being recorded 3 monthly to comply with the Regulations set out by the Care Standards Act they must be carried out on a monthly basis. Stapely Nursing DS0000025179.V263691.R01.S.doc Version 5.0 Page 17 Minutes of meetings held in the home were examined. The meetings are held monthly for staff and 6 monthly for residents and relatives. The home operates a comment card system so people can anonymously raise issues. Medication audits are carried out monthly to check compliance. Resident are encouraged where possible to handle their own money, families are encouraged to be involved if appropriate. Resident’s money handled in the home is documented clearly and receipts are kept for any expenditure. There is no supervision sessions being held in the home, however, the home manager has recently introduced a new care team system to address this problem, supervision sessions are planned for later in the year. Appraisals are planned for beginning of next year. The Health and Safety of the home is maintained, certificates for all aspects of the home were viewed and found to be valid and in date, they are kept in the administrators office in separate file. Fire drills and tests are carried out weekly these are documented accordingly. Stapely Nursing DS0000025179.V263691.R01.S.doc Version 5.0 Page 18 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 n/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 n/a 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 3 3 3 Stapely Nursing DS0000025179.V263691.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP33 Regulation 26 Requirement The registered person is required to complete monthly Regulation 26 Visits and forward a copy to the local CSCI office Timescale for action 01/12/05 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 2 3 Refer to Standard 19 30 32 Good Practice Recommendations It is recommended that the lounge carpet at the front of the premises is replaced as it is heavily stained. It is recommended that staff receive the recommended 6 supervision sessions each year. It is recommended that the manager be totally supernumery so to ensure the home is managed appropriately Stapely Nursing DS0000025179.V263691.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Stapely Nursing DS0000025179.V263691.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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