Inspection on 28/07/05 for Stapleton House

This inspection was carried out on 28th July 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 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 19/05/08

Stapleton House 25/05/07

Stapleton House 31/08/06

Stapleton House 07/02/06

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Stapleton House Back Borough Road Jarrow Tyne and Wear NE32 5XW Lead Inspector Mrs P A Worley Announced 28 July 2005 10:00am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Stapleton House B52 B02 S276 Stapleton House V213514 28 Jul 2005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Stapleton House Address Back Borough Road Jarrow Tyne and Wear NE32 5XW 0191 430 0179 0191 483 3294 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Exceler Healthcare Services Limited Mrs Margaret Mary Gregg Care Home with nursing 45 Category(ies) of PD Physical disability (4) registration, with number OP Old age (45) of places PD(E) Physical dis - over 65 (6) Stapleton House B52 B02 S276 Stapleton House V213514 28 Jul 2005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11/1/2005 Brief Description of the Service: Stapleton House is a purpose built home providing both personal and nursing care for up to 45 older people. It is a two storey building serviced by two passenger lifts. All bedrooms except one are en-suite, and there are four lounges, one with an adjoining conservatory, and three dining rooms. The corridors and doors are wide and allow access for people using wheelchairs. 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. Stapleton House B52 B02 S276 Stapleton House V213514 28 Jul 2005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced, and was carried out by one Inspector over one day. Before the inspection a questionnaire had been completed by the Manager, which gave up to date information about the Home to allow more time to be spent with residents on the day. A tour around the home to check the cleanliness, health and safety matters, and maintenance and decoration was carried out. The Inspector spoke with fifteen residents, two visiting relatives, and seven staff including the cook, and the Manager. The Inspector also had lunch with some residents in one of the three dining rooms. A number of records and documents were examined including residents’ care plans, staff files, maintenance certificates and complaints. An action plan had been received from the Provider following the last inspection and all but one of the requirements and recommendations from that inspection have been completed. Not all standards were assessed at this inspection and from those that were; one requirement and one recommendation were made. A number of CSCI comments cards were received before the inspection from service users and relatives and all were generally very complimentary about the Home and the staff. What the service does well: The Home offers a homely and comfortable place to live. Staff have a good knowledge of residents needs, and are friendly and helpful to residents and visitors. Some residents who were spoken to said: “the staff are very nice, very kind”, “ I don’t know where I’d be without them” and “the staff are very good to me, I’m very happy”. The Home provides meals that are varied, and choices and alternatives are available. Some residents commented that the portions were too large at times but the food was always good. Stapleton House B52 B02 S276 Stapleton House V213514 28 Jul 2005 Stage 4.doc Version 1.40 Page 6 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. Stapleton House B52 B02 S276 Stapleton House V213514 28 Jul 2005 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Stapleton House B52 B02 S276 Stapleton House V213514 28 Jul 2005 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 & 4. A range of information is available which enables service users to make an informed decision about whether they would like to move into the Home. The admission procedures ensure that service user’s needs are assessed prior to care being offered at the Home and confirmation that the Home can meet their needs is given to them in writing. This helps to ensure that they are offered and receive the care they need. EVIDENCE: A Statement of Purpose and Service Users Guide is available to current residents and prospective residents, which gives information about the Home, the staff and the services provided. A corporate document has been prepared and issued to the Home by the Company and the Manager has included information of interest about the local community and facilities there, and other specific information about Stapleton House. The files of the two most recently admitted residents were looked at and evidence was available of assessments by Care Managers, the Home’s preStapleton House B52 B02 S276 Stapleton House V213514 28 Jul 2005 Stage 4.doc Version 1.40 Page 9 admission assessment, and further assessment by the Home’s staff at the time of admission. Evidence was also available of residents’, and relatives’ involvement in this process. Stapleton House B52 B02 S276 Stapleton House V213514 28 Jul 2005 Stage 4.doc Version 1.40 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 standard(s) 7 & 8. Service users appeared well and spoke of staff meeting their health and personal needs. Service user’s care plans are in place but still do not fully reflect and document all of their observed needs. This can limit the guidance available for staff regarding care practice and how to meet those needs. EVIDENCE: In conversation with the Manager and other staff, they displayed a good knowledge of individual residents and their needs. They were able to say how those needs would be met and how identified risks were managed. The care plans of two residents were inspected and contained good basic information but more, and specific detail, about the care delivered and addressing changing needs should be recorded. Health related risk assessments were carried out and care plans as to how they were to be acted upon were in place. The care plans contain information and records of the input by GP’s and other relevant professionals. Evidence of evaluations and reviews was also available. The Manager indicated that care plan audits are carried out and this would be the ongoing responsibility of the Care Manager/Deputy, but this post is currently vacant. Residents who were spoken with, and one visiting relative, described how the health care needs were met. One resident said, “they look after my health Stapleton House B52 B02 S276 Stapleton House V213514 28 Jul 2005 Stage 4.doc Version 1.40 Page 11 very well, because I couldn’t”, and a relative who visits daily said “ my wife’s health is much better since he came here, I’m happy with her care and the staff are good to me”. Stapleton House B52 B02 S276 Stapleton House V213514 28 Jul 2005 Stage 4.doc Version 1.40 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 standard(s) 15. The meals in the Home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: Lunch was taken with some residents in one of the three dining rooms. The environment was bright and pleasant and the tables were attractively set with tablecloths, napkins, condiments, cutlery and a decoration. Two meal choices were offered and alternatives were available for those who requested them. Tea and/or fruit juice was offered during the meal. The meal was tasty and well presented. A number of residents however, said that the portions were too large and two ate less than half of the meal provided as a result, although they said they had enjoyed what they had had. Staff assisted residents who needed it, in a discreet and sensitive manner and the occasion was pleasant and sociable. One relative of a resident, who visits the home six days a week, attends at lunchtime and joins his wife for lunch. He spoke of how good the food was and how helpful the staff were to both him and his wife. A menu board is displayed on the wall in the dining room, but was not completed. This is not helpful if it is to inform or remind residents of the meals Stapleton House B52 B02 S276 Stapleton House V213514 28 Jul 2005 Stage 4.doc Version 1.40 Page 13 for the day. Residents confirmed that it was usually filled in and when asked if it was helpful said: “yes, as we often forget what we have ordered”. This was brought to the attention of a member of staff who said it had been an oversight on this day. Stapleton House B52 B02 S276 Stapleton House V213514 28 Jul 2005 Stage 4.doc Version 1.40 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 standard(s) 16 & 18. The Home has a satisfactory complaints procedure, which ensures that complaints are handled objectively, and residents indicated that their concerns are listened to, taken seriously and acted upon. Through the Home’s Protection of Vulnerable Adults Policy and procedure and staff training, service users are protected from abuse. EVIDENCE: A complaints procedure is available, which includes appropriate timescales, who complaints should be made to and how they will be dealt with, and information on referring complaints to the CSCI. The procedure is available within the homes policy file and the service users guide. Records of complaints are kept and were inspected. Outcomes and action for prevention of recurrence are recorded. Residents who were spoken with said they knew who they could go to if they had a concern or complaint, as did one relative who was asked. The Home has a Protection of Vulnerable Adults Procedure (POVA) in place and a copy of the Local Authority’s Procedural Framework for the Protection of Vulnerable Adults, is available to staff. Staff records and those that were spoken with confirmed that they had received POVA training and were able to satisfactorily describe what actions and procedures should be taken on suspicion of abuse or if abuse was seen to take place. Evidence of staff training in this area was seen in some staff files. Stapleton House B52 B02 S276 Stapleton House V213514 28 Jul 2005 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,25 & 26. The home was well maintained and decorated, with continued re-decorating of communal areas taking place, offering a homely, pleasant and safe environment for residents to live. Residents live in warm and comfortable surroundings that are clean and odour free. EVIDENCE: A tour of the premises was carried out. The ground floor lounge has been decorated since the last inspection and new curtains and armchairs provided. The room has a fresh and homely look and residents there commented on how pleasant and comfortable it was. The light fittings are domestic in character but the light levels appeared dim and the Manager was advised to have the lux lighting levels checked to ensure that they are no less than 150 lux. A loop system is provided in this room to assist those people with hearing difficulties when watching television. Stapleton House B52 B02 S276 Stapleton House V213514 28 Jul 2005 Stage 4.doc Version 1.40 Page 16 The Manager advised that the first floor lounge was due to be decorated in September as part of the ongoing decoration programme. A plan of the Home’s decoration programme was seen and residents’ bedrooms were also included in the ongoing programme. One bedroom that had recently been decorated and refurbished to the residents’ taste was seen and was bright and homely, whilst another one viewed had a stained and worn carpet and was in need of decoration. All bedrooms seen were warm and homely and contained items of residents personal belongings. All areas of the Home were clean and free from odour. Certificates and other records were available and seen to confirm regular and up to date servicing of equipment and systems. At the time of the inspection liquid soap dispensers were being fitted to all en-suite rooms in the Home. The Manager indicated that these, together with paper hand towel dispensers were being fitted as part of the Company’s measures to aid control of infection. Stapleton House B52 B02 S276 Stapleton House V213514 28 Jul 2005 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 29. Staffing levels and skill mix are sufficient to effectively meet the needs of service users living in the Home. The procedures for the recruitment of staff provide the safeguards to offer protection to people living in the Home. EVIDENCE: Discussions with the Manager indicated that appropriate numbers of staff are provided and maintained over the twenty-four hour period to meet the needs of the current residents. The Manager works supernumerary to the rota, and a good level of ancillary/support staff are in post. In response to a recommendation made by CSCI arising from a complaint the Home now provides an additional care assistant in the evening to ensure that a member of staff is always available to attend to a residents’ needs when other staff are busy and not immediately available. There is currently no Care/Deputy Manager in post. In conversation with some residents they said they felt safe living in the Home and were well cared for. They commented that the staff were kind and helpful. A number of Commission for Social Care (CSCI) comments cards were received from service users and relatives that indicated that there were not always sufficient staff on duty, however the staffing rotas indicated that minimum numbers were maintained. The call system was tested on one occasion during the inspection and response time by staff was acceptable. Stapleton House B52 B02 S276 Stapleton House V213514 28 Jul 2005 Stage 4.doc Version 1.40 Page 18 Inspection of two staff files confirmed that appropriate checks are carried out prior to staff taking up post that includes Criminal Records Bureau (CRB) and POVA register checks, and two written references being obtained. Evidence was also seen of induction training for new staff. Stapleton House B52 B02 S276 Stapleton House V213514 28 Jul 2005 Stage 4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 & 38. Staff receive appropriate supervision, which assists in promoting and safeguarding the best interests of service users. The health, safety and welfare of service users and staff is promoted and protected through training and staff practices. EVIDENCE: Discussions with a number of staff confirmed that they receive regular and appropriate supervision, records of which are kept, and evidence of this was seen. Staff commented that they felt valued and supported and that Manager was approachable and helpful. All staff receive training in health and safety, which includes moving and handling, first aid, food hygiene, Control of Substances Hazardous to Health (COSHH), fire safety, infection control and risk management. Throughout the day staff demonstrated awareness of good health and safety practice. Moving Stapleton House B52 B02 S276 Stapleton House V213514 28 Jul 2005 Stage 4.doc Version 1.40 Page 20 and handling procedures by staff with the residents, were observed to be good with appropriate practices carried out. No hazards were identified at this inspection, other than the recommendation to have the lux lighting levels checked in the ground floor lounge. ‘Dorgard’ self-closure devices have been fitted to fire doors that need to be kept open for operational reasons, the cleaners and chemicals on the domestic trolley were appropriately contained and the domestic member of staff confirmed training in matters of health and safety including COSHH. Stapleton House B52 B02 S276 Stapleton House V213514 28 Jul 2005 Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x x 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x 3 x 3 Stapleton House B52 B02 S276 Stapleton House V213514 28 Jul 2005 Stage 4.doc Version 1.40 Page 22 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15 Requirement Residents care plans must reflect all assessed and changing needs. Timescale for action 31/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 25 Good Practice Recommendations The lux lighting levels should be checked to ensure they are at the minimum of 150 lux to assist those people who have visual difficulties and avoid the risk of accident. Stapleton House B52 B02 S276 Stapleton House V213514 28 Jul 2005 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Baltic House Port of Tyne, Tyne Dock South Shields NE34 9PT 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 Stapleton House B52 B02 S276 Stapleton House V213514 28 Jul 2005 Stage 4.doc Version 1.40 Page 24 - 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!