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Inspection on 19/01/06 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 19th January 2006.

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

The home manages all medication to a high standard. The residents stated they enjoyed living in the home as they felt professional and friendly staff met their needs.

What has improved since the last inspection?

There has been some improvement to the environment since the last inspection. The carpet in the front lounge has been replaced. The home must ensure a maintenance programme is developed to maintain the home to a good standard for all who live in it.

What the care home could do better:

Care plan documentation must be in place for all residents so to ensure the correct care is delivered. Activities need to be recorded so to provide accurate evidence that residents` social and cultural needs are being met.

CARE HOMES FOR OLDER PEOPLE Stapely Nursing North Mossley Hill Road Liverpool Merseyside L18 8BR Lead Inspector Andrea Morris Unannounced Inspection 11:00 19 & 25th January 2006 th 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.V279062.R01.S.doc Version 5.1 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.V279062.R01.S.doc Version 5.1 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.V279062.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 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.V279062.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over two days due to the manager being on annual leave. The inspector spoke to residents, staff and the manager. A tour was made of the home; documentation was examined including staff files and residents care files, along with certificates relating to Health and Safety and fire prevention. 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.V279062.R01.S.doc Version 5.1 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.V279062.R01.S.doc Version 5.1 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, 5, 6 Residents are only admitted following a full assessment of their needs, ensuring the service is able to meet the needs on an individual basis. EVIDENCE: Since the last inspection the homes Statement of Purpose has been up dated to reflect the changes in the homes management structure. The Statement of Purpose is clear and concise and is available from reception upon request. Every resident who enters the home receives a contract that clearly defines their terms and conditions of residency. The manager or a suitable designated person carries out a pre-admission of potential residents. This ensures the needs of the resident can be met prior to admission. Any one considering coming into the home is welcome to visit the home, they can stay for a few hours or if they prefer stay for a meal at no extra cost. The home does not provide intermediate care. Stapely Nursing DS0000025179.V279062.R01.S.doc Version 5.1 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 Not all residents have care plans to reflect their needs, this must be implemented so to promote the meeting of needs and the safe delivery of care. EVIDENCE: A selection of residents care files was examined. It was found that care plans were reviewed on a monthly basis along with risk assessments. However, one care file was found to have no care plan written despite the resident being living in the home for one week. Another resident did not have a care plan for a specific care need that was being reported on daily. Documentation relating to other healthcare professionals visits were well maintained. Medication was examined and found to be managed appropriately. Evidence was seen that drug sheets were completed correctly. It was witnessed during visit that residents were treated with respect, many residents stated that the staff respected any decisions they made and they felt their dignity was protected at all times. Stapely Nursing DS0000025179.V279062.R01.S.doc Version 5.1 Page 9 The home follows strict Jewish practices relating to care of the dying; some staff have recently received training from the Jewish Council regarding customs and practices of Judaism. Stapely Nursing DS0000025179.V279062.R01.S.doc Version 5.1 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 The meals are well balanced and nutritious. The assist with maintaining residents’ health and are culturally appropriate. EVIDENCE: Activities are provided on a regular basis by volunteers from the community and staff within the home. During the visit a music therapy session was being held. Many residents stated they enjoyed the class. Other activities are also enjoyed by residents; such as outside entertainers, and the regular pianist who visits weekly. The home needs to provide documentation to support resident’s involvement in activities. The home operates an open visiting policy; families are encouraged to participate in home activities. The home maintains its links with the local community, particularly with the Jewish Community. Residents stated they were offered choices in how they wished to spend their day. Residents confirmed they were able to spend time in their room if they chose to. Stapely Nursing DS0000025179.V279062.R01.S.doc Version 5.1 Page 11 The meals served in the home are Kosher. The menus are rotated on a four weekly basis. Residents are able to request additional choices if they do not like the daily options. A couple of residents stated they did not always like the food, the manager stated the chef was now serving the meals in the dining room so to monitor more closely residents’ likes and dislikes. Stapely Nursing DS0000025179.V279062.R01.S.doc Version 5.1 Page 12 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 The Adult Protection policy is adequate and assists in protecting residents from harm. EVIDENCE: The home has an adequate complaints procedure. It is displayed in the main area of the home and gives details on how to contact the Commission for Social Care Inspection. Complaints received in the home are documented in the complaints book, the action taken and outcome is recorded against the initial complaint. Residents entering the home are registered on the electoral role, they are assisted in maintaining their right to vote by either accessing the postal voting system or by being assisted to the local polling station by either staff or of possible relatives. The home has recently revised all its policies and procedures, including the Adult Protection Policy. During the induction process staff receive training on Adult Protection, they are also given copies of the Whistle-blowing and Adult Protection policy. The manager has provided additional training to some staff on Adult protection; there are plans for the near future that the additional training be cascaded to all staff within the home. Stapely Nursing DS0000025179.V279062.R01.S.doc Version 5.1 Page 13 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, 22, 23, 24, 25, 26 The home is maintained to a good standard but a programme for re-decoration must be evident so as to maintain the home as a safe and comfortable environment. EVIDENCE: Since the last inspection the carpet in the front lounge has been replaced. During the tour of the home residents’ rooms were examined and found to be decorated appropriately. The home must ensure a rolling re-decoration programme is maintained to ensure the environment remains clean and pleasant for residents living in it. The home has specialist equipment such as hoists that are used. Service records were seen and found to be in date. The home is visited once a week by the homes physiotherapist, who monitors and assesses residents’ mobility needs and abilities. Stapely Nursing DS0000025179.V279062.R01.S.doc Version 5.1 Page 14 The residents are able to enjoy private facilities and are able to receive visitors in the privacy of their own rooms. Many rooms are of a large size. Residents on moving into the home are encouraged to bring in personal effects so to make their environment more homely. All the rooms seen during the visit were found to personalised and homely. The home is kept clean and tidy; there was no evidence of any malodours. Stapely Nursing DS0000025179.V279062.R01.S.doc Version 5.1 Page 15 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 process is adequate in promoting residents safety. EVIDENCE: Staff rotas were examined and supported that the home is appropriately staffed. The home does not use agency staff on a regular basis. 75 of staff have completed their NVQ2 and above. Two further staff are waiting to start their NVQ2 in the near future. A selection of staff personal files were examined and found to contain all the necessary information. Evidence was seen that all relevant checks had been completed. New training records have been developed so to monitor staff training and development. The manager to enable all staff to complete the annual mandatory training has devised a training plan. A new induction programme has been introduced; there are no new staff at present. The manager has also developed training packs on clinical issues so to aid care staff in delivering a high standard of care. Stapely Nursing DS0000025179.V279062.R01.S.doc Version 5.1 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, 36, 37, 38 The home is well managed; which helps promote a high standard of care for residents. EVIDENCE: The Registered Manager is registered with the Commission for Social Care Inspection. The manager has completed the Registered Managers’ Award. Both staff and residents stated the manager was approachable and friendly. They also stated they had confidence in the managers ability and felt she ran the home in the best interest of the residents. Quality Assurance is monitored in house by the use of Questionnaires, which are sent out to both families and residents to complete. Staff are in receipt of supervision on a two monthly basis. Stapely Nursing DS0000025179.V279062.R01.S.doc Version 5.1 Page 17 All policies and procedures have been reviewed and up dated. Accident books are maintained to a good standard and the manager reviews all accidents on a regular basis. Certificates relating to Health and Safety were examined and all were found to be in date and valid. Stapely Nursing DS0000025179.V279062.R01.S.doc Version 5.1 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 N/A 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 N/A N/a 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 N/A N/A 3 3 3 Stapely Nursing DS0000025179.V279062.R01.S.doc Version 5.1 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 OP7 Regulation 15 Requirement The registered person with the resident or their representative create a written plan as to how the residents’ needs in respect to Health and welfare are to be met. Timescale for action 31/01/06 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 Refer to Standard OP12 OP18 Good Practice Recommendations It is strongly recommended that documentation relating to social activities be maintained so to provide written evidence of residents’ participation. It is strongly recommended that all staff including ancillary staff receive annual up date training in Adult protection training. Stapely Nursing DS0000025179.V279062.R01.S.doc Version 5.1 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.V279062.R01.S.doc Version 5.1 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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