CQC report explained · a nursing home
What the CQC found at Stapely Residential and Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Medicines, recruitment, infection control and risk management were generally safe, although some safety checks and equipment monitoring needed updating.
- Effective?
- Good
- This question was not assessed during this focused inspection. The previous rating was used when calculating the overall rating.
- Caring?
- Good
- This question was not assessed during this focused inspection. The previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This question was not assessed during this focused inspection. The previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- Quality checks and management oversight were not always effective. Staffing information, risk assessments, building repairs and refurbishment needed further review.
What inspectors found, May 2021
Stapely Residential and Nursing Home was rated Good overall; inspectors found safe care, but management oversight and building repairs needed improvement.
This was an unannounced, planned focused inspection on 15 and 16 April 2021. One inspector spoke with people living there, relatives and staff, and checked care records, medicines, staff files and management records.
The home was rated Good for Safe. Inspectors found suitable staffing, safe recruitment, medicines that were well managed, and systems to protect people from abuse and infection. People and relatives said they felt safe and well cared for.
The home was rated Requires Improvement for Well-led, the same as at the previous inspection. Oversight of staffing, risk assessments, repairs and refurbishment was not always effective. The provider took immediate action on some repairs and equipment after the inspection.
This was a focused inspection of Safe and Well-led only. The other ratings were carried over from the previous comprehensive inspection, so this report does not give new findings about Effective, Caring or Responsive.
Safe medicines
Medicines were stored safely and managed by trained staff. Records of regular medicines were accurate and complete.
“Medications were well managed. The storage of medicines was safe and trained staff carried out regular audits and checks to ensure safe processes were in place.” from the report
Infection control
The home had infection control procedures for COVID-19. Staff had suitable protective equipment and people, visitors and staff were monitored for symptoms.
“Staff had access to plentiful supplies of appropriate PPE and were aware of current requirements.” from the report
Kind and supportive staff
People and relatives were positive about the staff and the culture of care. Relatives said they were kept informed about their loved ones.
“The staff have been lovely, they have been very helpful, they kept me up to date and were very good” from the report
Cultural needs
People had access to services and facilities that met their cultural needs.
“People had access to services and facilities that met their cultural needs.” from the report
Management oversight
needs fixingQuality checks did not always show that staffing, risks, repairs and refurbishment were being managed effectively. The Well-led rating remained Requires Improvement.
“Quality assurance procedures were not always effective in supporting a well-managed service.” from the report
Building safety and repairs
needs fixingSome areas needed maintenance and repair, and safety checks for fire risks and trip hazards needed updating. The provider said it took immediate action after the inspection.
“Some safety checks needed updating and improved oversight to ensure safe management of fire risk assessments and management of trip hazards.” from the report
Equipment monitoring
minorAids and equipment needed closer monitoring to make sure they were cleaned effectively. The provider confirmed that new equipment was purchased after the inspection.
“Aids and equipment needed monitoring to ensure effective cleaning.” from the report
- 01Which repairs and refurbishment identified at the inspection have now been completed, and how are they being checked?
- 02How are fire risk assessments and trip hazards now monitored?
- 03How do you calculate staffing levels, and how will this information be shared with people living here?
- 04What equipment has been replaced, and how do you check that it is cleaned and maintained safely?
- 05Has the manager's application for CQC registration been completed?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 20 May 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, February 2020
Rated Good overall; inspectors found safe, kind care, but leadership and quality checks still required improvement.
Inspectors visited without notice on 16 and 18 December 2019. They spoke with 25 people, 11 relatives and friends, staff, visiting health professionals, and reviewed care, medicines, recruitment and management records.
The home was rated Good for safe, effective, caring and responsive care. People said they felt safe and were treated kindly. Medicines were managed safely, staff were suitably recruited, people's healthcare and dietary needs were supported, and activities were available.
Well-led was rated Requires Improvement. Some checks did not identify problems with hot water and alert systems. Care plans did not always contain enough detail, and records about mental capacity decisions were sometimes incomplete. The home received three recommendations, but inspectors found no current breaches of regulations.
Safe medicines
Staff responsible for medicines had training, medicines were stored securely, and managers carried out regular checks. People said they received the right medicines at the right times.
“People's medicines were managed safely.” from the report
Kind and respectful care
People and relatives described staff as kind, respectful and helpful. People were involved in decisions and supported to keep their independence.
“People were treated with kindness, dignity and respect.” from the report
Food and cultural needs
The home provided a choice of food and drinks, including food prepared according to a Kosher diet. People could also practise their faith and use the synagogue at the home.
“All food produce was sourced, prepared and cooked in-line with the principles of a Kosher diet to meet the needs of people using the service.” from the report
Activities and community links
People had access to activities, cultural events, a café and support from the local community. This included opportunities to take part in exercise, music and outings.
“People had access to stimulating activities and cultural events both within the service and in the local community.” from the report
Quality and safety checks
needs fixingThe home's monitoring system did not identify that hot water temperatures were consistently low or that alert system checks needed improvement. More robust checks were introduced after inspectors raised this.
“The provider's monitoring system had failed to identify and action this.” from the report
Care plan detail
needs fixingCare plans and records were not consistent across the home. Some assessments were incomplete and some plans did not contain enough information about people's needs and wishes.
“The content and level of detail in individual care plans and records differed around the service.” from the report
Mental capacity records
needs fixingSome Deprivation of Liberty Safeguards applications and records about people legally entitled to make decisions were incomplete. Inspectors recommended following current best practice.
“DoLS applications did not always contain all of the information required to ensure that all aspects of people care and support was considered in the decision making process.” from the report
Registered manager
needs fixingThere was no manager registered with the CQC when inspectors visited. The provider was legally responsible for how the home was run.
“The service did not have a manager registered with the Care Quality Commission.” from the report
- 01What changes have been made to the checks of hot water temperatures and alert systems, and how do you know they are now working?
- 02How will you make sure every person's care plan contains complete, current information about their needs and wishes?
- 03How do you check that Mental Capacity Act and Deprivation of Liberty Safeguards records contain all the required information?
- 04Who is currently responsible for managing the home, and what is the plan for having a manager registered with the CQC?
- 05How will you keep relatives involved in care plan reviews when a person's needs change?
This was an unannounced inspection covering all five CQC questions, including the care provided and the premises. This explanation was written from the published report of 15 February 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Stapely Residential and Nursing Home
6 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- May 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Stapely Residential and Nursing Home →
- February 2020Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
Read what inspectors found at Stapely Residential and Nursing Home →
- January 2019Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2018Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Inadequate
- April 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- May 2011
Registered with the Care Quality Commission on 11 May 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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