Care Home: Stapely Residential & Nursing Home

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What the care home does well The home is in the heart of the Jewish community and receives support from volunteer`s, which enables people to stay in touch with the community and to continue practise their beliefs. This means that people do not become isolated from who they know and what they believe when they move into the home. This also means that visitors are frequent and are well known by staff. This helps to promote a friendly relaxed atmosphere in the home.People are also supported to carry on with their usual family activities. An example of this is that several people are supported to eat a Shabbat meal with their family on a Friday evening. People told us that they liked the staff and that they believed they were very well cared for. Comments were made to us, which included: " My mother could not be in a better place " Another said, " the nursing team are excellent- any concerns and the doctor is out straight away" And another stated," The staff and carers are absolutely marvellous and my husband is so well looked after" People also told us that "staff are wonderful, kind and caring and attend to all my needs" and " the staff always have time to listen and reassure forgetful residents" A relative told us " I`m very impressed with the caring staff who go out of their way to care for the residents The home provides a range of nutritious home cooked meals, which are prepared following kosher rules. People told us that: " Food is of a very high standard, portions are very good and tailored to residents needs. Staff make a big fuss at birthdays" and "The home will always provide an alternative if I don`t like what`s on offer" The homes presents as very clean with comfortable furnishings. Each bedroom is decorated and furnished differently which helps to give a homely feel. Health and safety is managed well which helps to ensure that the home is a safe place for people to live. What has improved since the last inspection? Improvements have been made to the records that staff make about peoples care (care plans). This means that staff have access to up to date instructions on how to give care and support to each of the people who live in the home. This means that the risk of someone receiving the wrong care is reduced. The manager has commenced medication audits which means that she regularly reviews and monitors whether staff are giving people their medication as it was prescribed by their doctor. This helps to safeguard people`s health and welfare. The manager writes to anyone who makes a written complaint telling them how she has investigated their concerns and any action she has taken if needed to rectify matters. This helps to reassure people that their concerns have been listened to and addressed. The staff team have undertaken a variety of training since the last visit. This training includes topics, which are not expected by the national minimum standards. This shows a commitment to develop the staff team and to ensure that staff have the necessary skills to care and support the people who live in the home. Staff told us that believed the training was very good and that they had received an induction when they first started which enabled them to care for the people who live at the home. The manager has worked hard in recent months to review all policies and procedures within the home. This means that staff have access to up to date information telling them how to carry out certain procedures and how the homes operates. This reflects good practise. What the care home could do better: Staff should consider expanding the information that they provide to people who are interested in moving into the home. This could include photographs of bedrooms or sample menus. Not every one is able to visit the home before they move in and this would help people feel as though they have been involved in making the choice rather than relying on their relatives and friends to look around the home for them. The manager should carry through her intention to continue to source a wound-mapping tool. This would enable staff to record wound sizes accurately, which would show whether wounds were healing, or not. Having this information could mean that staff are able to seek advice sooner when wounds are not healing as expected. A menu should be displayed near the dining room so that people are reminded of the choice of meals available that day. The manager sends surveys out to people to ask their opinion of the home and the care and support provided by staff. Gathering all of the results from the surveys and publishing them in a report could develop this process further. This report could then be made available to the people who live in the home or anyone else who took part in a survey. This would show people that the home are continually trying to improve and show people also that there opinion is important and acted on. This would help to empower people who live in the home.Records of personal allowances (peoples finances) should include two signatures for all transactions that have taken place. This will act as a safety check to ensure that transactions have been recorded correctly. CARE HOMES FOR OLDER PEOPLE Stapely Nursing North Mossley Hill Road Liverpool Merseyside L18 8BR Lead Inspector Mrs Joanne Revie Key Unannounced Inspection 13th March 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 Stapely Nursing DS0000025179.V351845.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.V351845.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 0151 724 4509 stapely@btconnect.com 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.V351845.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named resident over 65 years with Dementia Date of last inspection 24th July 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.V351845.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 the people who use this service experience good quality outcomes. Prior to the site visit taking place the manager was asked to complete a document called an AQAA. This is a document, which gives information about the services strengths and weakness, and future plans for the service to develop further. Once the AQAA was received, surveys were sent out to the people who live at the home and the staff who work there. Eight of these were returned to CSCI, which had been completed by people who live at the home and their relatives. Six were returned which staff had completed. During the site visit, discussions were held with people who live at the home, and their visitors. Their views have been included within the report. The site visit was unannounced .The manager made her self available so discussions were also held with her. A variety of records were viewed which refer to the health and welfare and care received by the people who live at the home. This review also included viewing staff records. Observations were carried out to assess how well staff interact with the people who live at the home and how staff deliver care. Examples of care and support were observed which showed that the manager and the staff team have good understanding of how to treat people as individuals and how to meet their diverse needs. The cost of living at the home is £468.23 per week with an extra monthly charge of £3.00 for the provision of toiletries. A chiropodist and physiotherapist are also available at extra cost. What the service does well: The home is in the heart of the Jewish community and receives support from volunteer’s, which enables people to stay in touch with the community and to continue practise their beliefs. This means that people do not become isolated from who they know and what they believe when they move into the home. This also means that visitors are frequent and are well known by staff. This helps to promote a friendly relaxed atmosphere in the home. Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 6 People are also supported to carry on with their usual family activities. An example of this is that several people are supported to eat a Shabbat meal with their family on a Friday evening. People told us that they liked the staff and that they believed they were very well cared for. Comments were made to us, which included: ” My mother could not be in a better place ” Another said, “ the nursing team are excellent- any concerns and the doctor is out straight away” And another stated,” The staff and carers are absolutely marvellous and my husband is so well looked after” People also told us that “staff are wonderful, kind and caring and attend to all my needs” and “ the staff always have time to listen and reassure forgetful residents” A relative told us “ I’m very impressed with the caring staff who go out of their way to care for the residents The home provides a range of nutritious home cooked meals, which are prepared following kosher rules. People told us that: ” Food is of a very high standard, portions are very good and tailored to residents needs. Staff make a big fuss at birthdays” and “The home will always provide an alternative if I don’t like what’s on offer” The homes presents as very clean with comfortable furnishings. Each bedroom is decorated and furnished differently which helps to give a homely feel. Health and safety is managed well which helps to ensure that the home is a safe place for people to live. What has improved since the last inspection? Improvements have been made to the records that staff make about peoples care (care plans). This means that staff have access to up to date instructions on how to give care and support to each of the people who live in the home. This means that the risk of someone receiving the wrong care is reduced. The manager has commenced medication audits which means that she regularly reviews and monitors whether staff are giving people their Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 7 medication as it was prescribed by their doctor. This helps to safeguard people’s health and welfare. The manager writes to anyone who makes a written complaint telling them how she has investigated their concerns and any action she has taken if needed to rectify matters. This helps to reassure people that their concerns have been listened to and addressed. The staff team have undertaken a variety of training since the last visit. This training includes topics, which are not expected by the national minimum standards. This shows a commitment to develop the staff team and to ensure that staff have the necessary skills to care and support the people who live in the home. Staff told us that believed the training was very good and that they had received an induction when they first started which enabled them to care for the people who live at the home. The manager has worked hard in recent months to review all policies and procedures within the home. This means that staff have access to up to date information telling them how to carry out certain procedures and how the homes operates. This reflects good practise. What they could do better: Staff should consider expanding the information that they provide to people who are interested in moving into the home. This could include photographs of bedrooms or sample menus. Not every one is able to visit the home before they move in and this would help people feel as though they have been involved in making the choice rather than relying on their relatives and friends to look around the home for them. The manager should carry through her intention to continue to source a wound-mapping tool. This would enable staff to record wound sizes accurately, which would show whether wounds were healing, or not. Having this information could mean that staff are able to seek advice sooner when wounds are not healing as expected. A menu should be displayed near the dining room so that people are reminded of the choice of meals available that day. The manager sends surveys out to people to ask their opinion of the home and the care and support provided by staff. Gathering all of the results from the surveys and publishing them in a report could develop this process further. This report could then be made available to the people who live in the home or anyone else who took part in a survey. This would show people that the home are continually trying to improve and show people also that there opinion is important and acted on. This would help to empower people who live in the home. Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 8 Records of personal allowances (peoples finances) should include two signatures for all transactions that have taken place. This will act as a safety check to ensure that transactions have been recorded correctly. 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. Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 9 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.V351845.R01.S.doc Version 5.2 Page 10 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): 3. The home does not provide intermediate acre therefore standard 6 was not assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home are provided with enough information to make a choice about whether they want to live there. This includes a face-to-face meeting with senior staff who also gain enough information about the person’s needs and wishes to be able to prepare for their arrival and plan their care EVIDENCE: We looked at records in the home that showed us that people have their needs assessed by a senior qualified nurse before they move into the home. People told us that they believed that the staff try hard to help people settle and that they had received contracts and other written information about the home. They also said that they had been given an opportunity to meet with senior staff from the home. This shows that people are given enough information to make a decision about whether they wish to live at the home and the staff Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 11 team have enough information to be able to plan their care and prepare for their arrival. The home provides nursing care specifically to people from the Jewish community. The manager told us that many of the people who move into the home have usually visited at some time to see friends and relatives so are already familiar with the homes layout and staff team. Written information, which is provided to people, could be improved to include sample menus and a brochure giving a brief overview of the home. Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 12 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): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at the home have their health care needs met by staff that have the skills to care for them. People are supported to receive their medications safely, which promotes their health EVIDENCE: Each person who lives at the home has an individual plan of care. We looked at these and found that the person’s needs had been clearly written by a senior nurse as well as their wishes and the care that they needed. Other records looked at showed that staff are following these instructions. This means that the people who live at the home are receiving the same care from everyone. The plans also included up to date risk assessment records. These records are used to identify any weaknesses in the person’s health and gave instructions on how to stop any deterioration happening. Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 13 The plans were easy to read; up to date and easy to follow. The plans could be improved further by ensuring that people or their representatives sign the plan to show that they have been consulted and agree with the care that is being given. This would help to empower people and encourage them to feel in control of their lives. During discussions with the people who live at the home and their relatives, they were asked if they believed staff respected their privacy and dignity. All agreed that staff did do this by ensuring they were never exposed unnecessarily and by ensuring that their bedroom door was closed when staff were delivering personal care. Comments were also made that the staff at the home were always polite to them. People were seen to be dressed nicely and appeared tidy in their appearance. Records also showed us that the staff at the home involve other health care professionals such as G.P.s, physiotherapists, dieticians, chiropodists etc in the care received by people who live at the home. Five people were spoken with who all had a good opinion on the care that they received and the staffs’ ability to be kind and caring. We also looked at surveys from other people who live at the home and their relatives. They also had good opinions. Quotes from discussions and surveys have been included in the summary section at the front of the report. The records we looked at also showed that some people require specialised equipment to reduce the risk of their health deteriorating. We looked at people’s bedrooms, which showed that this equipment was in place and was functioning correctly. Records at the home also showed us that staff have the skills and the knowledge to care for wounds properly and to promote healing. Staff had taken photographs of a wound to show that it was healing. The manager explained that she had tried to source a wound-mapping tool to enable staff to record accurate measurements also. We looked around the home and found some people were in bed because of their health needs. These people appeared clean and comfortable and attention had been paid to their nails and hair as well as their mouths. This is important as it shows that the staff are trying to promote their comfort and dignity. The homes medication storage systems were viewed. Mediation administration records contained signatures to show that medications had been given at the right time. Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 14 Procedures are in place to enable people to self-administer their own medication if they desire with staff support if necessary. Medications are locked in a secure trolley within a secure room. We also saw records that showed us that amounts of tablets arriving and leaving the home are also recorded. This means that there is a clear audit trail for all medications. The manager ahs commenced medication audits. This means that she is randomly checking medications and records to ensure that staff are managing medications safely. This is good practise. Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 15 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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home are supported to remain part of the Jewish community and to become involved in a variety of activities and outings if they choose. People enjoy a nutritious choice of meals, which are prepared under strict Kosher rules. EVIDENCE: We looked at records and held discussions with the manager and people who live at the home which showed us that the people who live there are still supported and involved in the local Jewish community. The home has a mini bus, which is used to take people to different locations within the community (Jewish community centre etc) to take part in various activities. These outings occur weekly on a Monday, Tuesday and Friday. Other outings to places of local interest also occur. For example on the day of the visit a group of ladies had planned to visit Liverpool College. These outings are open to anyone who lives on the residential unit as well as the nursing unit. The home arranges for an entertainer to visit weekly for sing alongs etc. The residential unit has a Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 16 synagogue, which is accessible to the people who live on the nursing unit. A candle lighting service is held every Friday to welcome Shabat and a full service is held every month on a Saturday morning. People told us that their family and friends were always made welcome by the staff at the home. We observed that staff and visitors were informal and friendly towards each other, which showed that trusting relationships had developed. The home receives support from volunteers from the Jewish community. They visit the home regularly and provide activities such as reminiscence, poetry reading and singing every Friday afternoon. The manager explained that they have also given talks to the staff on occasions about the Jewish culture, which is good practise and helps non-Jewish staff understand the Jewish culture. The manager explained that the support from the volunteers and the families to the home was invaluable and informed us that some go as far as helping wash the dishes on Christmas day so that staff have a little less work to do which was greatly appreciated. We observed one person who lives at the home using the phone in the office. No permission was requested and staff did not appear surprised by this. This shows that people are encouraged to treat the home as “ their own” which reflects good practise. We had discussions with people who lived in the home who told us that they go to bed when they choose and get up when they choose. They agreed that if they didn’t feel like doing something they didn’t have to. For example staff would help them to get washed if they didn’t feel like having a bath and vice a versa. Copies of the homes menu were viewed, which showed that a variety of nutritious home cooked meals, are offered on a daily basis with other choices available if people don’t feel like eating what’s on offer. Discussions with people who live at the home and with relatives confirmed this to be true. The home has a separate dining room, which is nicely furnished with table settings although people can take their meals in their own rooms if they choose. A cook is available every day to prepare all meals. People spoken with were positive about the standard of food served .The home is equipped with two kitchens (milk and meat) so that food can be prepared following the Jewish culture. A person known as the Shomer visits weekly to ensure that staff are adhering to strict kosher rules of food preparation, storing and serving. Both kitchens are spacious and equipped with stainless steel fittings and fixtures. Both appeared clean and very well organised. Records showed that staff are monitoring food temperatures when cooked as well as fridge and freezer Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 17 temperatures. This is good practise and shows a willingness to comply with food hygiene legislation. Staff are also completing the manual” safer food better business” which has recently been introduced by the Environmental Health Agency; this is further evidence of good practise. Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 18 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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People believe their concerns will be acted on and trust the staff to keep them safe EVIDENCE: We looked at the surveys that had been sent to us from people who lived in the home and their friends and relatives. They told us that they knew how to complain and who to complain too. A copy of the full procedure was available outside the office. Records were viewed which showed that the manager addresses any concerns within the specified timescale on the homes policy and responds to all written complaints in writing. However records could be improved by ensuring that the date of when actions are taken are included in those complaints and concerns which have been made verbally. This would act as further evidence that the manager is addressing all concerns within timescale. We looked at staff training records, which showed us that Staff have received training on how to protect people from abuse. Viewing the homes AQAA and a discussion with the manager showed us that the manager has a very good understanding of her role and how to support and protect the rights of the people who live at the home. We have not received any concerns or complaints about the service since the last inspection. Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 19 Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 20 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): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home presents as a clean comfortable place for people to live. EVIDENCE: We walked around the building and looked at communal areas, some bedrooms, the kitchen and the laundry room. The manager told us that plans are being developed for the home to move to a purpose built nursing home as the committee have recognised that the environment does not meet fully meet the recommended national minimum standards. In view of this we concentrated on the décor and furnishings within the building. The décor is maintained to a good standard and the manager explained that people could choose the colour of their bedrooms if they wished. The home has a variety of different sized bedrooms some of which have en Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 21 suite facilities. These were painted in different colours and each was personalised according to the person’s tastes. Many of the bedrooms contained small fridges so that people had snacks to hand if they chose. We looked at the furniture and found that it appeared to be of good quality. Efforts had been made to co ordinate bedding with room colours and curtains. The home has two lounges. One has the dining room leading from it. The home also has a reception area with seating that people were also seen using. Access is available to a well-kept garden at the back of the home. We looked at staff records, which showed us that staff have received training in infection control. A domestic is available everyday from morning until evening and also weekday mornings. Staff files also showed us that all domestic staff have achieved an NVQ level 1 in Housekeeping. The home appeared very clean and smelt pleasant. People told us that they believed staff worked very hard to keep it clean and tidy. Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 22 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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive care and support from staff who are qualified to care and who people like. Robust recruitment procedures help to keep people safe. EVIDENCE: Off duties showed that the staff team start and finish shifts at a variety times of the day, which means that more staff are available during busy times. The manager also explained that due to the support that the home receives from the Jewish community relatives and friends would often provide carers to take people out or to provide 1:1 care. We saw that one person was receiving care form a carer in this way. The atmosphere in the home was quiet and calm and staff were seen to support people in an unhurried manner. Many of the staff have been employed at the home for some time, which helps to promote consistency for the people who live there. Surveys and people spoken with all commented very positively on staffs ability to care. We had a discussion with the manger and looked at the AQAA and the staff training records. These records showed that only 6 of the 50 staff employed Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 23 have not achieved a national vocational qualification in care. These six staff have enrolled to start training for the award in the near future. This is greater than the 50 minimum recommended by the national minimum standards. Staff files showed that the expected necessary checks are carried out on all staff before employment begins. New staff undertake training called an induction, which covers the roles and responsibilities of their job and core values such as privacy, dignity and confidentiality. This could be improved further by ensuring all staff receive an induction in to the Jewish culture so that staff understand peoples beliefs and know how to provide support and care in a way, which is important to them. Staff files showed that staff have undertaken training to enable them to promote peoples health and welfare. A lot of this training has taken place in the last twelve months and has included training in Abuse awareness and protection of vulnerable adults, Care planning, First aid, Oral hygiene, Food safety, moving and handling, Infection control, Health and safety, mental capacity act, assessing risk and Tissue viability. Some staff have also had training in creative therapy which aims to provide staff with skills to distract people who may becoming distressed through confusion. Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 24 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): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is a safe place for people to live. The manager ensures that the home is operated within current legislation and has the skills to manage the home effectively EVIDENCE: A qualified nurse who has achieved the registered managers award manages the home. She is an experienced manager and is registered with CSCI to manage the home. This means that necessary checks have been undertaken to ensure that she is suitable to manage the service. Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 25 People and their friends and families are regularly asked to express their opinion of the home either through surveys or meetings. The manager has worked hard in recent months to review all policies and procedures within the home as part of a Quality Assurance procedure. This process could be developed further by gathering all of the results from the annual surveys and publishing the results in a report. This report could then be made available to the people who live in the home or anyone else who took part in a survey. This would show people that the home are continually trying to improve and show people also that their opinion is important. We looked at records of personal allowances, which showed that people’s monies are managed safely. However this process should be developed to include two signatures for all transactions that have taken place. This will act as a safety check to ensure that transactions have been recorded correctly. The manager does not cat as appointee for anybody who lives at the home. A variety of certificates, contracts and records were viewed which showed that the home complies with Health and Safety legislation by ensuring that the home is a safe place for people to live. The home is fully equipped to fight fire should one occur and staff receive regular update training on how to do this. . Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 26 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 27 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 OP3 Good Practice Recommendations Written information (brochure, pictures, menus) could be provided to people who are interested in moving into the home. This would help them to decide whether Stapley Nursing Home is the right place for them to live. The manager should carry through her intention to continue to source a wound-mapping tool. This would enable staff to record wound sizes accurately. A menu should be displayed showing the meals and choices available that day to assist people in making choices. The manager should ensure that she dates all actions taken to address any verbal concerns. This will show whether complaints have been resolved within timescale or not. Inductions for new staff should include an insight into Jewish beliefs so that staff understand what is important to the people that they are caring for. DS0000025179.V351845.R01.S.doc Version 5.2 Page 28 2. 3. 4. OP8 OP15 OP16 5. OP29 Stapely Nursing 6. OP33 7. OP35 The results of the annual surveys should be published in a report. This report could then be made available to the people who live in the home or anyone else who took part in a survey. This would show people that the home are continually trying to improve and show people also that their opinion is important. Records of personal allowances should include two signatures for all transactions that have taken place. This will act as a safety check to ensure that transactions have been recorded correctly. Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North West Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.northwest@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Stapely Nursing DS0000025179.V351845.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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