Inspection on 19/05/08 for Stapleton House

This inspection was carried out on 19th May 2008.

CSCI found this care home to be providing an Good service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Stapleton House 07/10/08

Stapleton House 25/05/07

Stapleton House 31/08/06

Stapleton House 07/02/06

Stapleton House 28/07/05

Stapleton House 11/01/05

Stapleton House 05/07/04

Stapleton House 06/11/03

Stapleton House 11/07/03

Stapleton House 23/10/02

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Stapleton House Back Borough Road Jarrow Tyne And Wear NE32 5XW Lead Inspector Irene Bowater Key Unannounced Inspection 19th & 21st May 2008 09:00 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 Stapleton House DS0000000276.V365678.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. Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stapleton House Address Back Borough Road Jarrow Tyne And Wear NE32 5XW 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) 0191 430 0179 0191 483 3294 stapletonhouse@schealthcare.co.uk The.willows@ashbourne.co.uk Exceler Healthcare Services Limited Manager post vacant Care Home 45 Category(ies) of Dementia (12), Old age, not falling within any registration, with number other category (31), Physical disability (10) of places Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: To service users of the following gender: Either Whose primary needs on admission to the Home are within the following categories: Old Age, not falling within any other category - Code OP, maximum number of places 31 Dementia - Code DE, maximum number of places 12 Physical Disability - Code PD, maximum number of places 10 The maximum number of service users who can be accommodated is 45 25th May 2007 2. Date of last inspection Brief Description of the Service: Stapleton House is a purpose built home providing both personal, nursing and dementia care for older people. It is a two storey building serviced by two passenger lifts. All bedrooms except one are en-suite, and there are lounges, one with an adjoining conservatory, and separate dining rooms. The corridors and doors are wide and allow access for people using wheelchairs. There is a 12-bedded dementia care unit situated on the first floor. This is a self-contained unit with individual bedrooms, dining room and lounge. There are adapted bathrooms, showers and toilets close to all resident areas. The home is located in a quiet, discreet area with well-laid gardens to the rear overlooking a green belt area, which offers a picturesque view from some bedrooms and the communal areas. The home is close to the town centre of Jarrow, to all amenities, and public transport, including the Metro railway system. Car parking facilities are available. The current fee rates range from £359 to £482 and includes the nursing care contribution, which is set nationally. Private fee rates vary from £430 to £460. Items not covered by the fees include, hairdressing, toiletries, newspapers and clothing. Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. Before the visit: We looked at: • Information we have received since the last visit on 25 May 2007. • How the service dealt with any complaints and concerns since the last visit • Any changes to how the home is run • The provider’s view of how well they care for people • The views of people who use the service and their relatives, staff and other professionals. The Visit: Two visits were made on 19 and 21 May 2008 totalling 10 hours. During the visit we: • Talked with people who use the service, relatives, staff, the manager and visitors. • Looked at information about the people who use the service and how well their needs are met. • Looked at other records which must be kept • Checked that staff had the knowledge, skills and training to meet the needs of the people they care for • Looked around the building the building to make sure it was clean, safe and comfortable. • Checked what improvements had been made since the last visit. • We told the manager and Operational Manager what we found. What the service does well: The staff collects information together about the person before anyone moves into the home to make sure they can meet their needs. Staff are friendly and have a good relationship with people who use the service, families and other professionals. Staff are making sure that they respect people’s rights to privacy and dignity. Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 6 Care was given discreetly and with sensitivity. There is good communication with other professionals to ensure peoples health care needs are met. The menus offer a variety of well-cooked nutritious meals. People can enjoy a healthy, well-balanced and interesting diet. People said: “The food is good” “I have no complaints about the meals” “There is always plenty of choice and enough to eat” Clear information is available should anyone have a concern or complaint about the care or service they are receiving. Visitors said: “I would go to the manager if I had a concern” “I have made a complaint and it has been dealt with” People have brought some small items with them making their own bedrooms individualised and homely. There are good recruitment procedures so that only suitable people are employed to work in the home. The manager is a qualified nurse and has many years experience of managing a care home. There are good quality assurance systems in place to help make sure care standards are improved in the home. The registered persons make sure that the home is a safe place for visitors and those who live there. What has improved since the last inspection? Individual positional change charts, fluid balance charts and food charts are now completed to a satisfactory standard. The light cords have been renewed. And there are no odours in the home The clinical waste bin has been replaced. Appropriate shelving has been provided in the sluice. Over 50 of care staff have completed National Vocational Training (NVQ) level 2. There is new manager and deputy manager who have completed audits and they are starting to improve the standards and to make sure that there is clear Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 7 leadership and direction given to all staff in the day-to-day management of the home. 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. The summary of this inspection report can be made available in other formats on request. Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 8 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 Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Standard 6 is not applicable to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are given detailed information about the home and receive comprehensive assessments of need to help them make the right decision about using the service. EVIDENCE: The home sets out the aims and objectives of the service in a Statement of Purpose, which is readily available. There is also a Service Users Guide that sets out the values of the home. This makes references to supporting the diversity of needs, cultures, and beliefs of all those involved in the home. Before anyone is admitted to the home a full needs assessment is undertaken by a Care Manager, Home Manager and where necessary the nurse assessor. Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 10 From this information the staff complete a care plan based on individual needs. Before coming to live in the home people can come and visit and spend some time getting to know the home. Also the home confirms in writing to each individual that they can meet their needs and everyone has a contract that sets out the terms and conditions while living in the home. Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care and access to health care services are good, demonstrating that peoples’ needs are being met. EVIDENCE: Each person has a plan of care based on the admission assessment carried out by care managers, the home manager and where necessary nurse assessors. Staff completes pressure sore risk, dependency, moving and handling, nutritional assessments using the Malnutrition Universal Screening Tool (MUST), continence and fall risk assessments. These tools are there to help staff understand the level of risk each person and help them complete a care plan. Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 12 During the visit to the home six care plans were looked at. The plans showed that risk assessments were reviewed and updated on a monthly basis. Some of the plans have not been updated when people’s care needs have changed. One plan for nutrition was dated July 2007 and the October 2007.The staff contacted the speech and language Team (SALT) about swallowing problems but the care plan still says “normal diet” when this persons is now on a “soft consistency diet”. The care plan for communication states, “remains a challenge”. There is no detail of what staff should do to support this person when they become anxious and distressed. Information about how a person is assisted to move around the home states, “move in appropriate way using designated equipment”. The care plans do not specify the specific moving and assisting equipment or techniques to assist that person safely. Another care plan was written in May 2005 and then reviewed in January and April This care plan states “repeatedly remind to use the buzzer” This person no longer has the capability to use the call system. Written comments include “care plan valid”; “continue planned care” and a care plan for “wandering” stated “keep doors shut at all times” Describing people in terms of their behaviour does little to promote person centred care. There was little evidence to show what management arrangements are in place to show what staff need to do when someone presents with any behaviour that would challenge. The new deputy manager is aware that the care plans need to be reviewed and is presently working with the staff to make sure they are person centred and developed to show how peoples previous history and lifestyle affects their current needs and aspirations. Three of the plans showed that this is starting to happen. Staff involve other professionals in the provision of care. Weights are regularly recorded and should there be weight loss or difficulty with eating or drinking, a referral is made to the GP and to speech and language therapists. Everyone has access to all NHS facilities to ensure their healthcare needs can be met. There are regular visits from GP’s and other health professionals including, dentists, opticians and chiropody services. Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 13 Appropriate pressure relieving devices are available. Several people have air cell mattresses and cushions to prevent pressure damage. Advice is sought from, occupational therapists, speech therapists and continence advisors. Visits from the multi disciplinary team are recorded in individual care plans. The home has comprehensive medication policies and procedures for staff to use. Records are in place for all medicines received, administered and disposed of. An audit of Controlled Drugs and the Medicine Administration Records (M.A.R.) showed no discrepancies. When staff are handwriting directions on the M.A.R. sheets there are not two witness signatures. This would show that the correct directions had been carried out and would reduce the possibility of error. The staff were kind and attentive and they made sure all care was given in private. People said that the “staff were good and kind” and also commented that “they are always rushed off their feet”. Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Opportunities to take part in meaningful activities and keep control of everyday decisions are limited. This prevents people from leading full and active lives. EVIDENCE: On the day of the site visit the activities person was on holiday. There was plenty of recent information to show that events have been organised both inside and out of the home. Events have included sit and get fit, Easter Egg competitions, pie and pea supper, clothes party, majestic movies, coffee morning, bowling at the Dunes and fish and chip suppers. The home also produces a monthly newsletter, which is delivered to everyone and contains news and articles of interest Staff haven’t fully developed care plans to show how peoples previous history and lifestyle affects their current needs and aspirations. Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 15 No planned or unplanned activities took place during the visit. One person said that “nothing ever went on and I have never been out apart from my family taking me”. Staff said “they did not have time to do activities as they were to busy”. There is a pleasant garden with nice furniture but only one person sat out in the sunshine. Staffing levels do not give any flexibility and the staffs main focus is to make sure people’s personal and nutritional care needs are met throughout the day. On the Dementia Care unit upstairs there were two staff supporting seven people. No meaningful activities took place throughout the day as “the activities person was on holiday so nothing was going on.” The armchairs in the lounge were against the wall and the television was difficult to watch as two dining tables and chairs obscured it. Many people are assisted to go to the dining room for meals. Breakfast was served at 9am and consisted of porridge, a selection of cereals, scrambled egg, bacon and tomatoes. Toast and preserves were available along with hot drinks. Mid morning and mid afternoon hot and cold drinks are served. People can also choose a selection of fruit from a large platter and have a choice of biscuits and home baked cakes. Lunch was served in the dining rooms and there was a choice of lamb casserole or mushroom tagliatelle, carrots, peas and boiled new potatoes. Dessert choices were Eve’s pudding and custard, yoghurts and ice cream. Plenty of drinks were served throughout the day. Staff were attentive and supportive but again there was not enough staff to support people individually on the nursing unit. Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good complaints and protection procedures are in place. People can be sure that their views are always listened to and that they are protected from harm. EVIDENCE: The Company have a detailed complaints procedure, which is easy to understand, and it is readily available in the home. The home now keeps a full record of all complaints including detail of any investigation and actions taken. There has been one complaint since the last inspection and this has been resolved at home level. Clear safeguarding adults policies are available and staff were able to say what they would do should they be concerned about care practices. Care staff are to complete further safeguarding training which links into the Local Authority procedural framework. There are currently no safeguarding referrals reported to CSCI or Local Authority. Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean and safe but limited investment during the last twelve months means that further work is needed to create a more pleasing place for people to live. EVIDENCE: The home is a two-storey building, which is service by two passenger lifts. A separate twelve bedded dementia care unit has been provided upstairs. There are dining rooms and lounges on each floor. One lounge leads to a small conservatory and a pleasant garden which people are able to access. Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 18 There has been limited redecoration and refurbishment during the last year. This means that many areas including lounges are looking tired and walls are damaged from wheelchairs and trolleys. Several of the chairs in the downstairs lounge are grimy from constant use. One small lounge is being redecorated and there are plans to use it as a “bar café area. There are also plans to refurbish the conservatory area. The blinds have been removed and the room is only sparsely furnished with a cane three piece. The seating is low and people with mobility problems may have some difficulty either sitting in or getting out of the chairs. The lounge carpet on the upstairs Dementia care unit had black marks on either from trolleys or foot wear. This room is a lounge but the dining room is to be redecorated and the dining room furniture is now in the middle of the room. Lounge chairs and now placed around the walls and the television is in the far corner making it difficult to watch. Doors have been painted in striking contrasting colours in order that they can easily be seen and door knocks and letter boxes provided so that so that they resemble a front door. There are tactile murals; pictures and photographs on the corridor walls and the handrails are painted bright blue so that people can see them easily. All of the bedrooms apart from one have an en suite facility. People have brought small items with them making their own rooms personalised and reflective of their previous lifestyle. People needing nursing care have access to profiling nursing beds and appropriate equipment. There are specialist baths, shower facilities and adapted toilets close to all areas. The shower room near to the front door is not used as it could compromise residents’ privacy and dignity. This room is used for storage of hoists, wheelchairs and obsolete equipment. It was confirmed that the water is run on a weekly basis in unused areas. One specialist bath on the twelve-bedded unit has been out of use over a year. The people living on this unit have to go downstairs should they choose to have a bath. Otherwise there is only a choice of using the shower. Bathroom 28 was also being used to store wheelchairs and scales. There were also personal toiletries stored on the shelves. The flooring in bathroom 29 is marked and there is discolouration in the shower. Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 19 The sluice disinfectors were working but the doors were not kept locked. The flooring and sinks in these rooms were not clean and tidy. The laundry was busy but clean and organised. The domestic staff continue to work very hard to keep the home clean and free from any odours. Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems around recruitment, selection and training of staff are satisfactory but the staffing levels are not sufficient to address the full range of needs of people living in the home. This means that people’s lifestyles are restricted and overall affects their quality of life. EVIDENCE: The manager has transferred from another home in the Company and a new deputy manager has been recruited. Many of the care and ancillary staff have been employed at the home for some time and have formed a stable team. The home has two units. On the nursing unit there is qualified nurse on duty throughout the day with five carers in the morning and four in the afternoon. The Dementia care unit usually has a senior carer and carer during the day. Overnight there is one qualified nurse and three carers on duty for the whole home. There are sufficient ancillary staff including laundry, catering, administration and activities organiser and a maintenance person. Agency staff are not used in the home. Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 21 The majority of the people who live in the nursing unit need two staff to support and help them in all aspects of their care. During the site visit to was evident that the focus of the day was making sure basic needs were met. Staff were spending the majority of their time taking people to and from bedrooms, lounges, dining rooms and toilets. People had to wait some considerable time to be taken to the lounge after lunch and breakfast. The reason for this is people need two staff to be transferred from wheelchair to their destination. Staff said that it was difficult to find the time to sit and talk to people. Visitors agreed saying it was difficult to find any staff and sometimes their relative had to wait when they needed assistance. The staff have had “Yesterday, Today and Tomorrow training but need to have some refresher training as a person centred approach to care is not evident on either unit. Comments of “there is nothing going on as the activities person is on holiday” and “sometimes X kicks off” does not show that staff have an understanding of how to support those who may become distressed or have memory loss. Six staff files showed that recruitment procedures are correctly followed to minimise the risks to people living in the home. There was evidence of completed application forms, two written references, Criminal Record Bureau checks and proof of identity. Personal Identification Numbers (P.I.N.) numbers of qualified nurses are checked with the Nursing and Midwifery Council to make sure nurses are registered. Most of the staff have previously completed mandatory training. However staff need refresher training in infection control and food hygiene. Given the diverse needs of the people living in the home further specialist training in caring for those with Multiple Sclerosis, brain tumours, stroke, swallowing difficulties and challenging behaviours need to be sourced. The manager is a “Yesterday Today and Tomorrow “trainer and plans to complete refresher training for the staff. Over 50 of staff have completed National Vocational Qualifications (NVQ) level 2 and some are working towards completing level 3. Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run by an experienced manager who makes sure that good quality assurance and safety systems are in place. This makes sure that the home is run in the best interests of the people living there. EVIDENCE: The manager has transferred fro another home within the Company. She has been previously registered with the Commission and is currently completing registration to become registered manager of this service. She is aware that changes in management may affect the staff and the service delivery and she has started to have regular meetings with staff relatives and Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 23 residents. This is to make sure that everyone understands how and why changes have to be made. Quality assurance and monitoring systems are in place and where problems have been identified plans are being put in place to put things right. The AQQA was completed and sent back within agreed timescales. The information gave a reasonable picture of the service. It would be useful if more detail could be given to show what has happened and how they plan to continue to improve the service. Staff said that “things are being put right” and “I can go and talk to the manager when I want” A relative said “there is always someone to talk to should I have a question”. The personal allowance records demonstrated that receipts and double signatures are maintained for all transactions. These could be cross-referenced and weekly checks are carried out to make sure there are no discrepancies. Regular maintenance checks are carried out both internally and from external contractors. These were up to date. A fire risk assessment is in place and fire records are up to date. The home had an inspection from the Fire Authority in February 2008. The manager has sourced refresher training in infection control and food hygiene. An appropriate record of accidents is maintained and there are systems in place to monitor and track trends. Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 24 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 3 X 3 X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 14,15 Requirement The registered persons must ensure that the care plans set out details of peoples care needs so that staff can deliver a person centred approach to care. The registered persons must ensure that handwritten entries on medication charts are witnessed to reduce the risk of mistakes when copying complex information. The registered persons must ensure that people are able to have the opportunity to choose their leisure activities and routines of daily living at all times. The registered persons must ensure that people are supported to make choices regarding their everyday lives and this must be recorded in detail The registered persons must continue with the redecoration and refurbishment programme of the home. The registered persons must ensure that the furniture and fittings in all communal areas DS0000000276.V365678.R01.S.doc Timescale for action 01/08/08 2 OP9 13 01/07/08 3 OP12 16 01/07/08 4 OP14 12 01/07/08 5 OP19 13,23 01/10/08 6 OP20 16,23 01/10/08 Stapleton House Version 5.2 Page 26 7 OP21 23 8 OP26 13,16 9 OP27 18 10 OP30 18 are of good quality and suitable for use. The registered persons must ensure that the specialist bath on the dementia care unit is repaired. Timescale of 01/07/07 not met The registered persons must clean or repair the flooring and shower in bathroom 29 The registered persons must ensure that the flooring and sinks in the sluice rooms are cleaned. Communal items must not be used as this increases the risk of cross infection and more importantly shows that people’s dignity may not be respected all of the time The registered persons must ensure The registered persons must provide sufficient numbers of staff at all times to meet the needs of individuals living in the home. The registered persons must provide training to ensure that the staff working in the home have the skills and experience necessary for the work they do. 01/08/08 01/07/08 01/07/08 01/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Stapleton House DS0000000276.V365678.R01.S.doc Version 5.2 Page 28 - 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!