Inspection on 07/02/06 for Stapleton House

This inspection was carried out on 7th February 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

Stapleton House 07/10/08

Stapleton House 19/05/08

Stapleton House 25/05/07

Stapleton House 31/08/06

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 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 Unannounced Inspection 7th February 2006 09:40 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.V268215.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. Stapleton House DS0000000276.V268215.R01.S.doc Version 5.1 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 the.willows@ashbourne.co.uk Exceler Healthcare Services Limited Mrs Margaret Mary Gregg Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45), Physical disability (4), Physical disability of places over 65 years of age (6) Stapleton House DS0000000276.V268215.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th July 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 DS0000000276.V268215.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out by one Inspector over one day. The majority of residents, the Manager, a number of nursing and care staff, domestic, laundry staff and the administrator were spoken to. A sample of records were inspected that included, care plans and resident’s finance records of personal allowances, and medication records. A tour of the building was carried out to check the facilities and equipment available for residents, and the general maintenance and safety of the Home. What the service does well: What has improved since the last inspection? New carpeting has been provided for the first floor corridors, which have also been decorated. A number of bedrooms have been decorated, with varying colour schemes and welcome packs and some are now available as ‘show’ rooms for people who may be thinking of moving into the Home, to see. New armchairs have been provided in the day/dining room on the first floor that look more inviting and homely for residents. Additional domestic staff hours have been provided and the benefit is shown in the good standard of cleanliness in the Home. Care staff NVQ training is progressing well and improves the skills of staff that provide the care to residents. Stapleton House DS0000000276.V268215.R01.S.doc Version 5.1 Page 6 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 DS0000000276.V268215.R01.S.doc Version 5.1 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 Stapleton House DS0000000276.V268215.R01.S.doc Version 5.1 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): 3 Appropriate assessments of service users needs are carried out prior to, and on admission and confirmation that the Home can meet their needs is given to them in writing Intermediate care is not provided by the Home (Standard 6). EVIDENCE: Inspection of a sample of residents’ care files and discussions with the Manager confirmed that appropriate assessments are carried out prior to admission to the Home. Care Managers, Nurse Assessors where relevant, a pre-admission assessment is carried out by the Home, also assessment on admission, and subsequently, where required. Evidence was available of residents, and/or their representatives’ involvement in this process. Stapleton House DS0000000276.V268215.R01.S.doc Version 5.1 Page 9 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, 9 & 10. Service users health, personal and social care needs are set out in an individual plan of care, to guide staff as to the care needs of the individuals’ to ensure that they are met. The systems in place for dealing with medicines are satisfactory and the arrangements ensure that resident’s medication needs are met. Personal care and support by staff is offered to residents in a way that respects, promotes and protects their privacy and dignity. EVIDENCE: Each resident has an individual plan of care and the sample viewed showed them to be up to date, clear and completed according to Ashbourne Healthcare’s format and policy. A good range of health related risk assessments were available and were supported by a relevant care plan. The Unit Manager carries out monthly audits of care plans and evidence of the most recent audit on 4th February 2006 was seen. The format provides for the documentation of evaluations of care but do not enable adequate statements to be written. Also some statements confirm only that the plans of care are Stapleton House DS0000000276.V268215.R01.S.doc Version 5.1 Page 10 monitored and not how effective the care plan is. Lengthy discussion with the Unit Manager took place regarding this and also the imminent introduction of the new Company’s care plan format, which may assist staff in documenting more meaningful statements. The arrangements for the ordering, storage, receipt, administration and disposal of medicines were inspected. All were satisfactory with the original prescription seen by the Home and copies kept, two signatures obtained when checking in medicines received, and good, clear Medicine Administration Records (MAR) maintained. However, where medicines are carried forward from the previous MAR sheet or instructions need to be transcribed by nursing staff, the numbers carried forward, and dates and signatures should be recorded. A new and comprehensive format document to audit medicines monthly has been introduced and evidence as seen of the last audit carried out. Daily stock checks of Controlled Drugs (CD’s) is carried out by two nurses who sign to confirm this, and a balance check of CD’s was carried out and was correct. A record of daily drug fridge temperatures is maintained. The storage arrangements are in line with appropriate guidance and the supplying chemist, who is licensed to do so, carries out the disposal of medicines. Residents described how staff maintained their privacy and dignity and that they knocked on their doors and waited for a reply before entering. Residents also confirmed that they were treated respectfully and in a kind manner by all members of staff, especially when personal care was being carried out, such as bathing. Staff were observed to treat residents in a sensitive and respectful manner, especially those who needed assistance. Stapleton House DS0000000276.V268215.R01.S.doc Version 5.1 Page 11 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. Residents are offered opportunities, and are encouraged, to participate in a variety of social activities, as and when they choose. Links with families, friends and the community are maintained and encouraged and service users are supported in making choices about their daily lives. EVIDENCE: An Activities co-ordinator is employed but was on leave at the time of the inspection. Conversations with the Manager, staff and residents, and the programmes displayed in the Home showed what various in-house activities and entertainments were organised and other planned events and outings. Minutes of a recent residents’ meeting were also displayed and showed that activities had been discussed as an agenda item. Links with the community are maintained and a number of residents spoke of the trips out to lunch at hotels and restaurants over the Christmas period and of visits out with their families and of their visits to the Home. Some residents spoke of the activities they preferred, or just having a quiet time watching television or chatting. Residents who prefer this life style said staff respected their wishes to spend time as they wished. They also confirmed that they choose what time they wish to retire and rise, have baths, Stapleton House DS0000000276.V268215.R01.S.doc Version 5.1 Page 12 and where they spend their time, and staff supported them in this. Visitors are welcome at any time and this was observed although no visitors were spoken with during this inspection. Residents confirmed that there were no restrictions on visiting and that they were able to receive visitors in private if they wished. Stapleton House DS0000000276.V268215.R01.S.doc Version 5.1 Page 13 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): Standards 16 & 18 were assessed and met at the last inspection. On this occasion residents indicated that they remain happy with the complaints procedure, and the Manager indicated that the appropriate recruitment procedures continue to be followed. EVIDENCE: Stapleton House DS0000000276.V268215.R01.S.doc Version 5.1 Page 14 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 & 25. The Home provides a safe, clean and well maintained environment for residents to live in. Recent decoration of the some areas has enhanced the homely appearance and image of the home. Residents live in warm, well-lit and comfortable surroundings that provide suitable and adequate toilet and bathing facilities. EVIDENCE: Since the last inspection new carpet has been provided to the first floor corridors, which have also been decorated. Some residents’ bedrooms have also been decorated and new armchairs have been provided in the day/dining room, along with accessories that make the room look more homely and inviting. A number of vacant bedrooms were viewed and are currently used as ‘show rooms’. All have been decorated and refurbished and have different, but co-ordinating and inviting colour schemes. Due to the new Company ownership of the Home the decorating programme planned for the communal rooms on the first floor has been rescheduled. Stapleton House DS0000000276.V268215.R01.S.doc Version 5.1 Page 15 All bedrooms with the exception of one have en-suite toilet facilities. Additional toilets are also provided throughout the Home, and also baths and showers that are suitable for people who need assistance. One shower room on the ground floor had hoists, chair scales and other equipment stored in it, but the Manager said this room was currently in use, as residents preferred the other bathing facilities provided at present. The Home was clean to a good standard, and odour free. Heating and lighting throughout the Home during this visit, was satisfactory. The laundry room was clean and well organised although in need of repainting in some areas to assist with cleaning, and some tiles need to be replaced on the wall adjacent to a drying machine. Stapleton House DS0000000276.V268215.R01.S.doc Version 5.1 Page 16 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): 28 & 30. Residents are supported and are in safe hands, as staff receive appropriate training in relation to the care needs of service users to enable those who are not already qualified, to qualify and competently do their jobs. EVIDENCE: Discussion with the manager and review of staffing rotas indicated that sufficient staffing numbers and skill mix are provided to meet the needs of the current residents. However, although the General Manager is usually also in the Home in the afternoons, only one nurse is provided in the afternoons and evenings to cover nursing duties for up to twenty-six nursing residents and management duties that may arise for up to twenty-nine residents, which is the current occupancy. In the absence of the General Manager for example, when on leave, no additional cover is provided, only support from General Managers of other Homes who ‘look on’. This is potentially unsafe for the Registered Nurse who may not always have experience in management and may require immediate support. Good levels of ancillary staff are provided including laundry, catering, maintenance and administration staff, and the increased domestic hours are reflected in the good standard of cleanliness in the Home. In discussions with the manager and a number of staff it was confirmed that appropriate training is given to staff to enable them to do their jobs competently. A number of care staff have qualified at NVQ Levels 2 and/or 3 and the remainder are either almost completed the training or are scheduled to Stapleton House DS0000000276.V268215.R01.S.doc Version 5.1 Page 17 commence training. At the time of the inspection the NVQ Assessor running the training programme was in attendance and was guiding and assessing staff coming to the completion of their training. She spoke of the enthusiasm and commitment by staff to gain the qualifications. Some care staff have commenced training in the safe administration of medicines offered by South Tyneside College. Training and development for staff includes all statutory training is set out in a rolling annual programme and evidence was seen of the scheduled training events. Specific training is also offered for nursing staff that includes areas such as continence care, moving and handling and attendance at dementia group meetings. The activities co-ordinator and another care assistant have completed first aid training specifically for the occasions when they take residents out in a care bus. The practices and procedures observed by staff indicated the value and effectiveness of the training given. Stapleton House DS0000000276.V268215.R01.S.doc Version 5.1 Page 18 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, 33, 35 & 38. The Manager is appropriately qualified and has extensive experience in care and related management, to competently run the home and service. Some systems are in place to determine the quality of the service provided by the Home, and ensure that it is run in the best interests of the residents. Appropriate systems are in place and function well, to safeguard service user’s personal allowances. Records are clear and well documented. Staff follow appropriate safe working practices to promote and protect service users’ health, welfare and safety. EVIDENCE: Stapleton House DS0000000276.V268215.R01.S.doc Version 5.1 Page 19 The Registered Manager is appropriately qualified and experienced to manage the Home. She is a Registered General Nurse, has extensive experience managing care homes, and has a number of qualifications related to her work, including palliative care, dementia care, elderly care and disability care. She also has a Diploma qualification in management, equivalent to level 5 and has recently completed a two-day course on risk management. The Company’s quality assurance systems are in place. A comprehensive Quality of Care Audit system has recently been introduced by the new Company and three monthly audit reports are to be sent to head office of specific areas of quality audit for example medications, care plans, health and safety to include food/catering, maintenance etc. Service user and relatives questionnaires are to be issued annually by the Company. Residents and staff meetings are held at least three-monthly with notes kept. Monthly reports of the conduct of the Home are available as required by Regulation 26 of the Care Homes Regulations 2001. Inspection of the arrangements for the personal allowances of residents was carried out. The Administrator deals with the records and monies held for residents at the Home. Residents’ personal monies are received into the Home from their families or by cheque from Social Services. Receipts and two signatures are available to back up transactions and all residents have individual record sheets of their accounts both for cash and monies banked. The hairdresser submits communal receipts to the Administrator and she agreed to speak with her to request individual receipts for each resident. It was recommended that all receipts are numbered and recorded on the transactions sheets to assist with checks and audits. The security arrangements and records of service users’, whose monies are held in the home, are well organised and well maintained. A random check of some residents’ monies held and their records showed them to be accurately accounted for. Weekly in-house audits are carried out and two-weekly reconciliation checks and a report are sent to head office. In conversation staff confirmed that they receive training in all areas of health and safety. Two domestic staff that were spoken with confirmed they had received training in Control of Substances Hazardous to Health (COSHH) and were to receive fire safety training in the coming week. Both demonstrated a good knowledge of COSHH practice and procedure. One member of the domestic staff has an NVQ qualification in Housekeeping. Throughout the day staff demonstrated awareness of good health and safety practices. Moving and handling procedures by staff with the residents, were observed to be good with appropriate practices carried out and equipment used. All doors with ‘keep locked’ notices were locked and fire safety practices were up held. Stapleton House DS0000000276.V268215.R01.S.doc Version 5.1 Page 20 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 3 X X X 3 3 STAFFING Standard No Score 27 X 28 2 29 X 30 3 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.V268215.R01.S.doc Version 5.1 Page 21 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. Standard Regulation Requirement Timescale for action 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 OP28 Good Practice Recommendations The programme of NVQ training should continue so that a minimum of 50 of care staff are qualified at, at least NVQ Level 2. Stapleton House DS0000000276.V268215.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection South of Tyne Area Office 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 DS0000000276.V268215.R01.S.doc Version 5.1 Page 23 - 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. 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