Inspection on 24/07/06 for Stapely Residential & Nursing Home

This inspection was carried out on 24th July 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.

Other inspections for this house

Stapely Residential & Nursing... 19/01/06

Stapely Residential & Nursing... 01/11/05

Stapely Residential & Nursing... 26/01/05

Stapely Residential & Nursing... 08/07/04

Stapely Residential & Nursing... 20/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Stapely Nursing North Mossley Hill Road Liverpool Merseyside L18 8BR Lead Inspector Andrea Morris Key Unannounced Inspection 10:00 24 & 25th July 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.V296830.R01.S.doc Version 5.2 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.V296830.R01.S.doc Version 5.2 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.V296830.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 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.V296830.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection which took 2 days to complete. A second inspector Ms Debbie Corcoran accompanied the lead inspector. During the inspection a selection of documentation was examined including resident care files, staff personnel files, health and safety certificates and financial records. The inspectors spoke with many residents, some visitors and a selection of staff that were working on the inspection days. What the service does well: What has improved since the last inspection? What they could do better: Care plans must be recorded for all residents and reviews must be made on an at least monthly basis. Risk assessments must be reviewed as the needs of the resident change to ensure accurate records are maintained. Stapely Nursing DS0000025179.V296830.R01.S.doc Version 5.2 Page 6 Medication must not be over stocked and the registered person must ensure stock control is maintained to a satisfactory standard. Complaints must be fully recorded including the outcome and action taken in relation to all complaints to provide an accurate record. The adult protection policy must be reviewed to ensure it complies with the Liverpool Adult Protection policy. 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.V296830.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Stapely Nursing DS0000025179.V296830.R01.S.doc Version 5.2 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 the following standard(s): 1, 2, 3, 4, 5, 6 Pre-admission assessments are completed prior to residents moving in to the home, this assists in ensuring potential resident’s needs can be met. EVIDENCE: The homes statement of purpose and service user guide were examined and found to contain all the necessary information required. Copies are issued to all residents or their families at the time of admission. Copies are available upon request from the main office. All residents entering the home are in receipt of a written contract. This clearly defines the terms and conditions of residency. All residents prior to admission are assessed by either the manager or designated suitably qualified person. On viewing several pre-admission assessments it was noted that not all assessments contained full details of a persons needs. Stapely Nursing DS0000025179.V296830.R01.S.doc Version 5.2 Page 9 The home records all family communications in the resident care files. Residents and families confirmed that they were actively involved in planning care and were kept up to date with the resident progress. Records are also maintained to a good standard in relation to professional visits, records are clearly recorded and give details of which professional has visited and the outcome of the visit. The home encourages potential residents to visit the home prior to moving in to the home. Potential residents are able to stay for a few hours or for a meal at no additional cost, prior to making a final decision. The home does not provide intermediate care. Stapely Nursing DS0000025179.V296830.R01.S.doc Version 5.2 Page 10 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 Care plans and risk assessments must be kept under review to ensure resident care is appropriate; thus promoting resident safety. EVIDENCE: A selection of care files were examined during the inspection, it was found that the majority of care files were completed. One resident who had been admitted 7 weeks prior to the inspection did not have any care plans documented. All residents must have care plans created to ensure care is provided appropriately. A requirement has been made to address this issue. It was noted that the care files that did contain care plans, not all were reviewed on an at least monthly basis. Care plans must be reviewed to identify any change in care and to ensure planned care remains appropriate. Risk assessments for residents were completed for all residents, however it was found that on one particular resident who’s risk had increased due to frailty and general deterioration in physical health no review on the risk assessments had been carried out since February 2006. A requirement to ensure all risk assessments are completed on an at least monthly basis or sooner has been made. Stapely Nursing DS0000025179.V296830.R01.S.doc Version 5.2 Page 11 The homes medication was checked, it was found that the recording of medication was accurate and all controlled drugs were stored and recorded correctly. It was noted that the home had excessive stock of some liquid medication, this practice must cease, and the medication must be managed to ensure medication is only held in the home as required. During the conversations held with residents all confirmed they were happy with the treatment they received from the staff, they stated that staff treated them well, and respected any decisions they made. Many of the residents stated they, “liked the atmosphere of the home, staff are very nice”. The homes policy relating to care of the dying is appropriate. Staff support all persons and provide all care as required. During the inspection one resident who was very poorly was noted to have a staff member present at all times, thus ensuring all needs were maintained. Stapely Nursing DS0000025179.V296830.R01.S.doc Version 5.2 Page 12 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 Activities are varied, thus assisting residents in leading a well balanced and culturally satisfying lifestyle. EVIDENCE: The home provides a good level of activities for all residents; residents who spoke with the inspector stated ‘the entertainment here is very good’. The programme is displayed in the entrance area of the home, includes quizzes, entertainers, bingo, music and exercise, and occasional visits to local areas and coffee mornings to the Jewish community. A service is held once a month and on holy days, the local Rabbi visits fortnightly. The home maintains strong links with the Jewish community many visitors were seen to be calling in during the day of the inspection. The home operates an open visiting policy, residents identified they could receive their visitors in private and staff respected their privacy. Stapely Nursing DS0000025179.V296830.R01.S.doc Version 5.2 Page 13 Many residents also stated that they were able to state how they wished to spend their day, some residents preferred to spend time in their rooms and others enjoyed time in the community areas chatting to each other and visitors. The home maintains the kosher practice, there are two kitchens and all cutlery and dishes are maintained separately as required under kosher rules. A Jewish leader visits the home several times a week to ensure the kitchen is run appropriately and to provide support and advise to kitchen staff. Menus were seen and found to be varied; Shabbat is celebrated on a Friday. On the day of the inspection the midday meal was salmon, residents stated that ‘it was lovely’. Generally residents were found to be happy with the meals, they confirmed that they could request an alternative to the main choices if they preferred. Residents are able to choose the day before their meal, all residents who spoke with the inspector stated they enjoyed the meals provided. Stapely Nursing DS0000025179.V296830.R01.S.doc Version 5.2 Page 14 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 Many staff are trained in adult protection, this assists in protecting residents from any potential harm. EVIDENCE: The home has an adequate complaints policy that was last up dated in February 2006. There have been no complaints made to the Commission for Social Care Inspection since the last inspection. All complaints are recorded in a book, however it was noted that not all actions taken in respect of the complaint were fully documented, and not all outcomes completed to ensure the complaint had been fully dealt with. The legal rights of residents is promoted, all residents entering the home are registered on the electoral role. Residents who wish to vote are offered the opportunity to access the postal voting system or if they prefer they are able to go to the local polling station, families are encouraged to assist their relative, however staff will do so in the event of no family members. Many staff have received training in adult protection. Staff who spoke with the inspector were able to identify what they would do if the need arose, the answers were acceptable to the inspector. There has been no adult protection referrals made since the last inspection. On examining the policy and procedure for adult protection it was noted that there was areas of weakness, the home must review this policy to ensure that Stapely Nursing DS0000025179.V296830.R01.S.doc Version 5.2 Page 15 the policy does not incur inappropriate actions taken that could damage a criminal investigation. Stapely Nursing DS0000025179.V296830.R01.S.doc Version 5.2 Page 16 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 The home is maintained to a satisfactory standard, thus providing residents with a homely environment in which to enjoy. EVIDENCE: A tour was made of the home and it was found to be maintained to satisfactory standard. All communal bathrooms were found to be satisfactory and in good state of repair. The dining room and conservatory were found to be maintained to an adequate standard and many residents were making good use of the facilities. All maintenance jobs are listed in a book and ticked off when completed. Residents stated they were happy with their rooms, all rooms were found to be personalised and maintained to a good standard. Stapely Nursing DS0000025179.V296830.R01.S.doc Version 5.2 Page 17 The home has sufficient number of hoists for moving and handling purposes; dates of regular checks were noted to be maintained. All water temperatures are checked and recorded appropriately. Stapely Nursing DS0000025179.V296830.R01.S.doc Version 5.2 Page 18 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 Staff receive regular training in all aspects of care, this assists in helping residents to remain safe. EVIDENCE: The staff rota was examined and found to be satisfactory. Currently the home is not using agency, staff within the home are covering current vacancies. The home is actively recruiting staff to ensure the staffing requirements are met. 66 of care staff hold a certificate in NVQ care. Some staff are waiting to commence on the programme no date set yet. Staff who spoke with the inspector stated that they received regular training, support was provided for all staff. Staff also confirmed that the induction covered all aspects of care including the individual resident’s needs. All staff that spoke with the inspector stated they were aware of their role and responsibilities as these were discussed during the 1-1 sessions with nursing staff and that they felt very supported by both other staff and the manager. A selection of staff files were checked and it was found that all staff where checked against the CRB (Criminal Bureau Records), staff files were found to contain all information as listed in Schedule 2 of the National Minimum Standards however, it was noted that a health check form was not completed Stapely Nursing DS0000025179.V296830.R01.S.doc Version 5.2 Page 19 for the staff files viewed and neither was there an interview notes contained in the files, a recommendation has been made relating to this. Stapely Nursing DS0000025179.V296830.R01.S.doc Version 5.2 Page 20 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 An experienced manager who provides strong leadership for staff and residents, thus promoting good standards of care, manages the home. EVIDENCE: An experienced manager, who provides staff with strong leadership, manages the home, this assists in ensuring good care standards are maintained for residents. The general view of staff is that they find the manager approachable and fair. The manager provides consistency and strives to develop the home and offers staff the opportunity to develop their skills. Residents also confirmed their approval in the manager, they stated they found her approachable and friendly. Stapely Nursing DS0000025179.V296830.R01.S.doc Version 5.2 Page 21 Not all staff receive regular supervision, which is recorded, this is necessary to ensure staff receive documented instruction and regular communication from senior staff. The home does not act as advocate for any resident. Personal money held for residents is held individually and all records were found to be correct. The money held for residents is held securely with restricted access to only selected staff members. The homes policies and procedures have recently been up dated in February 2006. The policies and procedures are held in files in the main staff office so all staff have access to read and keep themselves aware of current procedures. The homes certificates relating to health and safety were viewed all were found to be in date. Fire records were also viewed, staff receive regular up dates in fire evacuation procedures and training, all documentation is well presented. Stapely Nursing DS0000025179.V296830.R01.S.doc Version 5.2 Page 22 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 2 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 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 2 17 3 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 3 3 Stapely Nursing DS0000025179.V296830.R01.S.doc Version 5.2 Page 23 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 resident’s needs in respect to Health and welfare are to be met. (Previous timescale 31/01/06) The registered person shall keep service users care plans under regular review. The registered person must ensure unnecessary risks to health and safety of service users are identified in appropriate risk assessments and reviewed at appropriate intervals at least monthly. Timescale for action 31/08/06 2. OP7 15(2)(b) 31/08/06 3. OP8 13(4)(c) 31/08/06 4. OP9 13(2) The registered person shall make 31/08/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The registered person shall ensure that any complaint made under the complaints procedure is fully investigated. DS0000025179.V296830.R01.S.doc 5. OP16 22(3) 30/09/06 Stapely Nursing Version 5.2 Page 24 6. OP36 18(2) The registered person shall ensure that persons working at the care home are appropriately supervised. 30/09/06 7. OP38 24(4)(c)(v The registered person shall make 31/08/06 ) provision for reviewing fire precautions, and testing fire equipment, at suitable intervals weekly testing of the fire alarm system must be adhered too. 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 OP3 Good Practice Recommendations It is strongly recommended that all pre-admission assessments contain full details of a resident’s needs, this assists in making accurate decisions on offering residency and to planning care. It is recommended that the home obtain a copy of Liverpool Adult protection policy. It is strongly recommended that the home reviews the adult protection policy to ensure it complies with current legislation and meets the requirements required. It is strongly recommended that all interviews conducted relating to potential new staff are recorded and records maintained within staff personnel files. It is strongly recommended that health questionnaires be completed during the inspection process to ensure compliance with Schedule 2 of the National Minimum Standard. 2. 3. OP18 OP18 4. OP29 5. 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