Inspection on 22/12/09 for St Mary`s Convent & Nursing Home

This is the latest available inspection report for this service, carried out on 22nd December 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Mary`s Convent & Nursing Home 06/01/06

St Mary`s Convent & Nursing Home 07/09/05

St Mary`s Convent & Nursing Home 16/02/05

St Mary`s Convent & Nursing Home 03/08/04

St Mary`s Convent & Nursing Home 09/02/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Extracts from inspection reports are licensed from CQC, this page was updated on 14/03/2010.

Key inspection report Care homes for older people Name: Address: St Mary`s Convent & Nursing Home Burlington Lane Chiswick London W4 2QE     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Ram Sooriah     Date: 2 3 1 2 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 36 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 36 Information about the care home Name of care home: Address: St Mary`s Convent & Nursing Home Burlington Lane Chiswick London W4 2QE 02089944641 02089959796 stmarysnh@tiscali.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Society of St Margaret care home 61 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: Service Users to include 38 beds providing care with nursing and 23 beds providing personal care. The home to provide general nursing care to service users over the age of 60 Date of last inspection Brief description of the care home St Marys Convent was founded in 1896. Part of the building is listed but where possible the building has undergone modernisation and refurbishment. Although in a busy area of Chiswick, not far from the Hogarth Roundabout, the home still provides a quiet and peaceful surrounding. It is accessible by buses that pass in front of the home. The nearest underground station is Turnham Green, about fifteen minutes walk away. Access to the home is from the main road through an intercom. There is a car park for about 12-15 cars that is accessible from a side road via an electronic gate. The home is owned and managed by the Anglican Sisters of St Margaret. It is Care Homes for Older People Page 4 of 36 Over 65 61 0 0 61 Brief description of the care home registered as a Limited Company and a Charity. The homes website states that it is run, as far as possible, as an extended Christian family. The Sisters take an active role in the daily life of the home. The home has 38 beds on the ground floor for nursing care and 23 beds on the first floor for personal care. All the rooms are single, except for two double bedrooms. They are all en-suite with at least a toilet and wash basin. A few have showers or baths. The double bedrooms are at times used for single occupancy if people do not want to share, but there might be a premium added to fees. The home has a shaft lift and a platform lift. In addition to the usual facilities available in care homes, such as the laundry and kitchen, the home also has a chapel, a physiotherapy room, accommodation for the Sisters of St Margaret and some members of staff (separate from residents accommodation) and extensive well-maintained gardens. There are communal areas throughout the home and bathrooms and showers on all the floors. Many are equipped with disability equipment. The home charges 550-595 pounds weekly for personal care and 775-815 for nursing care. It does not charge any top-ups. At the time of the inspection there were 59 residents in the home. Care Homes for Older People Page 5 of 36 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The key unannounced inspection started at 11:15 on Tuesday 22nd December 2009 and finished at 17:45. It continued on Wednesday 23rd December 2009 from 10:3015:45. Our last key inspection took place on the 20th February 2007, when we rated the service as providing excellent outcomes for people who use the service. We carried out Annual Service Reviews on the 26th February 2008 and 9th December 2008 and monitored the home from notifications about significant events in the home and from feedback that we receive from time to time about care services from people that use the services, their relatives and social and healthcare professionals. During the course of this inspection, we toured part of the premises and looked at a sample of records. We also talked to four visitors, six residents and six members of staff. When we finished the inspection we gave feedback to the manager of the home. Care Homes for Older People Page 6 of 36 An Annual Quality Assurance Assessment (AQAA) was also received from the service. This was very well completed and has been used in writing this report. We also carried out a satisfaction survey and received twelve satisfaction questionnaires from residents. At the time of the inspection, the home was preparing for the Christmas celebrations and many residents were looking forward to Christmas. We would like to thank all the people who contributed and supported us during the inspection. Care Homes for Older People Page 7 of 36 What the care home does well: We did not receive any negative comments about the service when we talked to residents, visitors or staff. When we asked whether there was something that could be improved in the home, people could not identify anything that could be improved. The satisfaction questionnaires provided a similar feedback. There was very little that people mentioned that could be improved. The home received many positive comments from residents and visitors when we talked to them. They say that staff always have a smile on their face and that they enjoy doing their job. Visitors say they are always made to feel welcome and are kept informed about changes in residents conditions. The home has a comprehensive statement of purpose and a comprehensive service users guide (SUG). The SUG is offered to all residents/representatives to inform them about the services that the home provides so that they can decide if they would like to receive a service from the home. The home also has a web-site with useful information about the service. The preadmission assessment of the needs of residents is carried out to a good standard, to make sure that the home only accepts residents whose needs can be met in the home. As a result the home is quite comfortable in meeting the needs of the residents that live in the home. The home liaises and communicates well with other healthcare professionals in the community to make sure that the needs of the residents are being met. The provision of activities and meals was rated very good in satisfaction questionnaires. 100 percent of people were always satisfied about the activities that are provided in the home and the meals. It is very rare for us to receive satisfaction questionnaires when all respondents are satisfied about activities and meals.With regards to activities people said that there is always plenty to do both inside and outside the home. One person said that there is always a choice of excellent food. The home provides a homely, clean and warm environment for residents. Residents and their relatives are able to personalise their rooms to make them as homely as they want to. The garden provides many different pleasant areas for residents to enjoy. There is a stable and consistent group of staff that are familiar with the needs of the residents. They receive training in mandatory and clinical areas to make sure that they are competent to do their work. There is regular supervision of nursing and care staff to make sure that they are appropriately supported in their job. Staff say in questionnaires that the home is a friendly and pleasant place to work. The manager is approachable by staff, residents and visitors. She knows all the residents and visitors well, and maintains a good relation with them. Staff say that they are well supported by the homes management and that they all feel part of a team. Staff rate the the standard of training that they receive as high. The home has an effective quality assurance and quality control systems in place, to Care Homes for Older People Page 8 of 36 measure the quality of the service and to ensure continuous improvement. Health and safety issues are taken seriously and the home makes sure that relevant checks and maintenance of items of equipment are carried out to ensure the safety of all people who use the premises. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. Care Homes for Older People Page 9 of 36 The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 10 of 36 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 36 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides all the necessary information to people for them to make an informed decision about using the service. The manager ensures that only peoples whose needs can be met, are offered a place in the home. Evidence: The home has a statement of purpose(SoP) and a service users guide(SUG). A copy of the SUG is left in each residents bedroom. There is a section of the care plan that addresses whether residents are able to access this document and to what extent they need support to understand the content. The SoP and the SUG have in the past been judged as comprehensive. We were shown documents to show that the manager has visited residents that were referred to the home to assess their needs prior to them being offered a place in the home. The preadmission assessments were on the whole completed appropriately and Care Homes for Older People Page 12 of 36 Evidence: described the needs of residents. The manager is clear that she will only admit people to the home whose needs can be met in the home. Residents and visitors who talked to us told us that they knew about the home from their research, from word of mouth and from the reputation of the home. Two visitors stated that they knew about the home because they live close to the home and pass by it. Another said that they found out about it from the local authority that provided a list of care homes. A resident stated that they know about the home because of their religious affiliation and wanted to be admitted to the home because of its background and facilities in terms of practising their religion. The home has a website with information about its history, management and the service that it provides. A brochure is also available on the website. All twelve people who responded to satisfaction questionnaires stated that they received enough information about the service before they moved in. The manager confirmed that although the home is owned by the Sisters of St Margaret, an Anglican order, it will also admit residents from other cultural and religious backgrounds as long as the needs of the residents would be met in the home. We asked the manager about the homes terms and conditions of the placement. We were informed that all residents, including those that are publicly funded receive a copy of the statement of terms and conditions for them to be aware of their rights and obligations. This was confirmed by people who responded to our questionnaires. They all said that they have been given a written statement of terms and conditions. Care Homes for Older People Page 13 of 36 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care records are not individualised enough to fully address all the needs of residents. As a result, there is no guarantee that the needs of residents would always be met to the same standard. The home takes the healthcare needs of residents seriously and supports them in meeting these needs as far as possible. Medicines management is not carried out as comprehensively as possible to ensure the safety of residents. Residents are always treated with dignity and respect. End of life care of residents are addressed in the care records and are met to a good standard. Evidence: The home has been introducing a computerised system for care plans during the past few months. The old paper care records were being phased out to be replaced by the new electronic records system. The computerised care records consist of the admission details of the residents, an Care Homes for Older People Page 14 of 36 Evidence: assessment of their needs, including some information about the social and recreational needs, risk assessments and an action plan for each need and risk that has been identified. The cultural and religious needs of residents were to some extent addressed but we noted that in some cases the religion of residents was identified as Christian. While the majority of residents are from the Church of England faith, we were informed that the home does admit residents from all other faiths. It would therefore be appropriate for the care records to include full information about the religion of residents and whether they practice their religion. We found that the care records that were kept were general and not individualised enough. It seems that prompts are generated by the electronic records system when the care plans are completed and that staff then have to choose the most appropriate prompts and personalise the care plan to the individual resident. We found that the care records did not always identify the specific needs of residents and there was no clear action plan in a number of cases to address the needs of residents. For example the computerised care records do not clarify the exact mobility needs of residents, the number of staff to assist residents with moving, the type of equipment to use and the manoeuvres where residents would need support. The care records for the prevention of pressure ulcers do not clarify the equipment to use and the repositioning regime in place to prevent pressure ulcers from developing. The care plan to assist a resident with personal hygiene stated that the resident requires full assistance with personal hygiene but did not clarify what assistance was needed. The care plan to manage incontinence said to use appropriate aids but did not clarify what the appropriate aids were and at what frequency these needed to be changed. Hard copies of the residents care plans were printed and these were signed by residents or their representatives to show that they have agreed to these. We were shown bed rails risk assessments and other risk assessments where there could have been restriction to the liberty of residents that were also agreed with residents or their relatives. Residents and visitors who talked to us told us that their care is discussed with them. Some remember having signed the care records. The falls risk assessment, nutritional risk assessment, manual handling risk assessment and waterlow risk assessment were in place for each resident and in a paper format. Our inspection of these records showed that the frequency to review the Care Homes for Older People Page 15 of 36 Evidence: risk assessments was not always clear. While the review should ideally be dependent on the risk that residents faced in regards to each of these risk assessments, the time scales to review the risk assessments were not clearly identified in the care records. In some cases, the risk assessments were planned to be used in a reactive manner rather than in a proactive manner. For example we were informed that the falls risk assessment was reviewed every six months (some staff said three monthly) or when the resident sustain a fall. The nutritional risk assessment was reviewed three monthly or when there is a change that requires the nutritional risk assessment to be reviewed. These tools should rather be used on a regular basis to detect any changes so that staff can put in place a preventative plan if changes have occurred, rather than to wait for something to happen and then review the risk assessments. We checked whether computerised entries about the care of residents could be edited. We noted that whilst care staff could not edit any entries, nursing staff were able to edit entries about the care of residents. This is a weakness of the system as no one should be able to edit entries about the care of residents without an appropriate audit trail, to preserve the authenticity of the records. There were two residents in the home with pressure ulcers. One of the residents had two pressure ulcers. Whilst there was a care plan to address one the pressure ulcers, there was no care plan to address the other pressure ulcer. The care plan that was in place was not clear about the frequency of wound dressing. There were no photos or wound mapping and no wound progress notes to provide information about the status of the ulcers. We were assured that the pressure ulcers were healing but there was no evidence in place to substantiate this. We noted that there was no pain chart in place to monitor the level of pain that a resident experienced. There was evidence that the analgesia had been reviewed to make the residents more comfortable and that staff were aware of the need to monitor whether the resident was in pain. However, a pain chart would have been a useful tool to monitor the level of pain and would have provided more comprehensive information about the effectiveness of the analgesia in providing pain relief. Records were in place to show that residents were seen by various healthcare professionals. The GP visits the home weekly and residents are referred to other healthcare professionals according to their needs. The home also employs physiotherapists and physiotherapists assistants to assess and support residents with mobility, muscolo-skeletal and chest complications. The manager stated that the home has close links with the local hospice and that support is sought whenever necessary. Care Homes for Older People Page 16 of 36 Evidence: Satisfaction questionnaires show that all twelve residents who responded, were happy with the support that they receive in meeting their healthcare needs. They said that staff take prompt action when they are not feeling well. The care records contained information about the wishes and instructions of residents with regards to end of life care. Staff knew that this is an area that they need to address in care plans. Statutory notifications that we have received about the death of residents in the home showed that the death of residents was generally well managed for a satisfactory outcome. The manager stated that a number of staff in the home have received end of life care training. We noted during the inspection that the home had its own form to record the resuscitation status of residents. However, we were informed that the home was in the process of implementing the latest guidance from the resuscitation council about the resuscitation status of residents. The home keeps the medicines of individual residents in their individual bedrooms. All bedrooms have a locked medicines cabinet, fixed to the wall, for the storage of medicines. There is a cabinet in the treatment room for the storage of excess medicines and another cabinet for the storage of controlled drugs (CD). We checked the CD records and noted that these were up to date and matched the amount of CD in stock in the home. Medicines are prescribed every three months and delivered every 28 days. The medicines charts are continuous and not only for 28 days. We audited the medicines of eight residents. We found that the medicines charts were mostly signed and the amount of medicines to administer when a variable dose was prescribed, was recorded. The location to apply topical medicines was also identified on the medicines charts. On at least two occasions we noted that changes to the dosage of medicines were not signed and dated. The strength of the medicines were crossed and rewritten over. We were therefore not sure when the changes were made. Ideally, instructions for the administration of a medicine should be re-written clearly when changes are made to the dosage. In a few cases entries were not written properly. Instead of writing a description of the medicines, the dosage was entered. This can lead to errors. The home did not use a monitored dose system. Dossette boxes and the nomad system were used for some residents who self-medicate while, a few were supported or supervised by staff to administer their own medicines from the original packs. Risk Care Homes for Older People Page 17 of 36 Evidence: assessments were in place for those residents that administered their own medicines. We noted that the home did not keep an overall balance of medicines. In some cases medicines remained from a previous 28 days supply and it was difficult to audit the amount of medicines without an overall balance of medicines. To audit in the short term, the home kept a record of the date of opening of a container/pack of medicine on the container/pack. However, a number of medicines did not have a date of opening because this was not recorded when the containers/packs were opened. As a result, we were not able to fully audit the amount of medicines that should have been in place. For those that had a date, we noted that the amount that should be in place did not always match the amount that was in place. This suggested that residents did not always receive the right amount of medicines because if they did then the amount of medicines in stock would match the amount that should be in stock. The home did not have the right lancing device to use for testing the blood sugar of residents who are diabetics. A device for self-use was in place instead of a professional device to be used by staff. The use of inappropriate lancing devices can increase the risk of blood borne cross-infection. Care Homes for Older People Page 18 of 36 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a range of indoor and outdoor activities to suit the needs of all residents that live in the home. The home provides a variety of nutritional meals to meet the individual choices of residents. Evidence: We looked at the care plans of residents and noted that these to some extent addressed the social and recreational needs of residents. There was some information about the life history of residents but this area could be developed further to provide a better perspective on the background of residents to fully ensure a person centred approach. The homes does not employ an activities coordinator but there are many people that are involved with the provision of activities. These include the sisters who live on the premises, volunteers and staff. Sister Jennifer, the responsible individual, is very involved in the provision of activities in the home and prepares a programme for the day to day provision of activities. Feedback about the provision of activities shows that residents enjoy the wide range Care Homes for Older People Page 19 of 36 Evidence: of activities that are provided. Five people wrote in satisfaction questionnaires that they enjoy the activities that are provided. One said that they have never known a home that offers so much activities. Another said that there is always a lot of activities to join in. On the day of the inspection there was a film session. An area of the home has been fitted with a cinema system with a large screen that is used by residents to watch films. A few residents were observed engrossed in a game of Scrabble. Other people that we spoke to, preferred to stay in their rooms to read, watch television or just relax on their own. Some residents have their own computers with internet access which they use to surf the net or keep in touch with friends and relatives. Other activities where residents can take part in, include reminiscence, exercise to music, reading groups, board games, card making, and art and craft. The home has a mini bus and a van adapted for wheelchair users. It has recently employed a driver. Outings are arranged to local places of interest and to places further from the home. Examples of outings are visits to the local parks and trips to the seaside. One resident said that they went to the seaside in summer and that they enjoyed their trip. The home already has a number of communal areas that can be used for activities. We however, observed that the home keeps improving its facilities to improve the quality of the life of residents. For example, there was a newly constructed activities room in the garden to be used mainly for cooking and gardening and raised flower beds have been provided to allow residents take part in gardening sessions. At the time of the inspection a conservatory was being erected to increase the opportunity for residents to enjoy the view of the garden. Indeed, for those that do not want to do anything and just relax, the home provides a pleasant garden and a few water features. Many bedrooms have large and low windows that faced the gardens to enable residents see out of the windows and to enjoy the peaceful and serene view of the garden. There is a chapel on site and there is a daily service and regular prayer sessions for people with the Church of England faith and for those who wish to attend. Some residents attend the sessions daily and others attend when they want to or with their relatives. There is a section in the chapel for wheelchair users. The home has a four weekly menu system. We were informed that residents are asked about their choices for meals the day before and these are recorded. The choice lists Care Homes for Older People Page 20 of 36 Evidence: are then used to dish out residents meals. All residents and visitors that we spoke to said that they are satisfied with the meals and that they are given choices. Residents receive a cooked breakfast during the week and have cereals during the weekend. A resident said that they look forward to the cooked breakfast. Another told us that the meals are very good. Satisfaction questionnaires showed that 100 percent of respondents were happy about the meals that they receive in the home. One person commented that the food is always very good and imaginative. Three said that the food is excellent and two mentioned the range of choices. The home serves three main meals a day and we were informed that staff serves biscuits, toasts and sandwiches and a hot drink at about 21:00 according to residents choice. Residents are offered a choice of two main meals at lunch and supper and if they do not want these an alternative is offered. On the day of the inspection, lunch consisted of chicken supreme, broccoli and cabbage, rice or potato and salad. Supper consisted of tomato soup, pork pie, salad, scrambled egg and toast. For desert there was jelly and cream, cheese and biscuits and fresh fruits. Meals are served in three areas of the home at different times. Residents are allocated to the different dining areas according to the level of assistance that they require to ensure that they can be supported appropriately by staff. The meals are served at different times to ensure that there are enough staff in each dining area. This arrangement seems to work and no one raised any concerns about this and instead residents seem to favour it as they say that they can get the support that they need when they need it. The kitchen was awarded a 5 star rating from the local authority. It was indeed kept very clean and all records as required by legislation were maintained. Care Homes for Older People Page 21 of 36 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home takes complaints and allegations and suspicions of abuse seriously and makes sure that these are dealt with appropriately. Evidence: The SUG contains a copy of the complaints procedure. It is given to all people that use the service and is available in the bedrooms of residents. Our satisfaction questionnaires show that the majority of people that use the service are aware of the complaints procedure. They all said that they know who to speak to if they are unhappy about the service that they receive. During the inspection we also talked to people about how they would raise concerns if they had any. They said that they would speak to the nurses or to the manager. Some said that there are various other people within the home with whom they can raise concerns. The responsible individual is on the premises and so is the liaison officer and the quality manager for the service. We looked at the records that the home keeps about complaints. Since the last key inspection, the home has reviewed the format of the complaints form for recording complaints. Complaints were appropriately recorded with information about timescales and responses. The complaints records showed that there have been eight complaints within the past Care Homes for Older People Page 22 of 36 Evidence: year. All complaints whether informal or formal were recorded. Information was available about how these were addressed and responded to. The home made one referral to the safeguarding adult team of the local borough. The allegations were investigated as required and were not substantiated. Conversation with the manager showed that she was fully aware of the local procedure for the reporting of allegations of abuse. Staff that we spoke to during the course of the inspection were also aware of the action to take if they come across allegations or suspicions of abuse. Care Homes for Older People Page 23 of 36 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a homely, comfortable and maintained environment where the needs of residents can be appropriately met. Evidence: Part of the building is listed and dates back to 1896. The home is surrounded by a high wall. There is an entrance to the home for pedestrians and wheelchair users on the main road and access is allowed through a buzzer system. There is a car park for about 12-15 cars within the premises of the home, that can be accessed by an entrance on a side road. The gate is managed electronically by reception staff. The home is surrounded by gardens that are very carefully maintained and that provide a very peaceful and pleasant surrounding. The building is well managed and we did not note any area of disrepair. There seems to be continuous improvement of the premises to improve the experiences of people that live in the home. The manager kindly provided a five year redecoration plan and stated in the AQAA that the plan for 2009 has been met and that the home would now implement the plan for 2010. The redecoration plan was comprehensive and addressed all areas of the home including the gardens and the replacement of furniture, to maintain and improve the quality of the environment, where required. Residents who responded to comment cards rate the environment of the home highly. Care Homes for Older People Page 24 of 36 Evidence: Some like the size of the rooms, other praise the fact that the rooms are airy and light, some like the patio doors in their bedrooms that open on the gardens. One person mentioned that the state and decor of some bathrooms could be improved. The home was generally free of odours. An odour that was present in the St Andrews wing in the morning disappeared in the afternoon. The majority of people who gave feedback said that the home is always fresh and clean. The building has large windows that let in natural light. This helps to provide an airy and bright environment. The home was also quite warm, considering that it was quite cold outside and despite the building being quite old and spread over a large surface area. We observed during the inspection that the communal areas are airy and appropriately decorated and furnished. We noted that there are many areas over the home that offer residents opportunities to sit where they wish. During the inspection we found that a few residents also chose to stay in their bedrooms. Items of furniture in the communal areas, including the dining areas, are in good condition and suitable for the needs of residents. Most bedrooms are large and offer a good amount of space. Most also have large and low windows that provide a pleasant view over the garden that surrounds the home. We observed that many residents brought some of their personal furniture and personal belongings to provide a homely environment for them. One resident said that they had an excellent room with a lovely view on the garden. Another said that they could organise their room to suit their needs. Items of furniture and the fixtures and fittings that the home provides, were in good condition. Many divans beds have been replaced and the home has plans to purchase a number of adjustable beds annually and to phase out all divans. We were informed that all residents that require an adjustable bed have been provided with one. We indeed noted that residents who had poor mobility and who required an adjustable bed have been provided with one. We observed that the home has a number of specialised chairs for residents according to their needs to enable them to sit out. Other items of equipment are available as required to promote the independence of residents. We saw many hoists throughout the home and noted a chair lift on a small set of stairs on the first floor. The home also has a shaft lift and a platform lift. The AQAA mentioned that the garden is fully accessible to wheelchairs. We did note many paths around the garden for residents with wheelchairs. A few residents have electric wheelchairs to use when they go out in the community. Care Homes for Older People Page 25 of 36 Evidence: Training records show that most staff were up to date with infection control.The manager mentioned in the AQAA that the home carries out regular infection control audits so that all staff are audited annually. The AQAA also said that gloves, aprons and other protective clothing are provided to all staff as required and that all staff, including ancillary staff receive training in infection control. There are two sluices on the ground floor with the appropriate bins for clinical waste. The manager stated that all clinical waste is disposed of in the appropriate clinical waste bins according to their nature and as soon as these are created. The home has a contract in place for the disposal of its clinical waste. Care Homes for Older People Page 26 of 36 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staffing levels that the home provides are suitable to ensure that the needs of residents are met. The standard of training that is provided to staff is appropriate for them to be competent and skilled enough to care for residents. The recruitment procedures are adhered to, to ensure that only suitable people are offered employment in the home. Evidence: The manager kindly provided copies of the duty roster that we analysed when we looked at the staffing levels that are provided in the home. The ground floor is divided in three smaller units: St Andrews, St Raphaels and St Josephs. Two of the smaller units, St Raphaels and St Josephs are quite close to each other and more than often is run with one trained nurse during the day and carers with an NVQ level 3 in each of the units. In the morning there are usually seven and in the afternoon five members of staff on the St Raphaels and St Josephs. This number at times includes two trained nurses and at times one trained nurse. On St Andrews there are five members of staff in the morning and at least three members of staff in the afternoon. At night the whole ground floor is run with one trained nurse and with at least one Care Homes for Older People Page 27 of 36 Evidence: carer with an NVQ 3 qualification on each of the wings on the ground floor. There is a total of four carers for the ground floor. Staffing on St Margarets, the unit for people requiring personal care on the first floor, consists of four carers in the morning, three in the afternoon and one at night. In addition to care staff, the home has ancillary staff in the kitchen, for domestic duties, in the office and for maintenance. It has recently recruited a driver and also has many volunteers and the Sisters of St Margaret who support the home. Satisfaction questionnaires from residents showed that nine out of the twelve respondents say that staff are always available when they need one and that staff always listen to then and act on what they say. Three residents said usually to the above. Two residents commented that there are friendly and helpful staff. Another said that they look after me well and are kind and caring. We looked at the personnel files of three members of staff that have been recently recruited to work in the home. Appropriately completed application forms and recruitment checks were in place. We noted that all employees had a signed contract in place. There was evidence that CRB checks were carried out and for those who needed to start work earlier a PoVA first check was available for inspection. We noted that all of the applicants had references in place but one of them did not have a reference from the last employer. It is recommended that a reference is always sought from the last place of employment of an applicant. The manager stated that all new employees involved in caring and supporting residents receive induction that includes the common induction standards from skills for care. There were records in place to show that all staff receive one to one supervision. Members of staff that we talked to also confirmed that they receive supervision and training. The home keeps a training matrix with records of training that staff have undergone. The records showed that on the whole staff were up to date with manual handling, fire training, food hygiene, abuse training, infection control and health and safety training. In addition to that, there have been training in medication, understanding diseases in old age such as stroke and Parkinsons disease, and in palliative care. The home has more than 66 percent of staff qualified to at least NVQ level 2 in care. The AQAA informs us eight members of staff are studying for an NVQ level 4 in care. Care Homes for Older People Page 28 of 36 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a strong and effective management team to ensure that the aims and objectives of the service are met. The quality of the service is monitored and audited to ensure that people are satisfied with the service that is provided. Most health and safety issues are taken seriously and are addressed as required. Evidence: The manager has been in post for about nine years and has an NHS background. She is a nurse and has a management qualification although she does not yet have the Registered Managers Award. The manager is very involved in the care of residents and provides hands on care at times. We noted that she is approachable to residents and is familiar with their needs. She keeps an active presence in the home and is also familiar with the residents relatives and visitors. Feedback about the manager from residents, visitors and staff was positive. They all said that she listens to them and takes action as required. One resident who sent us a Care Homes for Older People Page 29 of 36 Evidence: satisfaction questionnaire said that the support of the home has been very helpful. Another said in a questionnaire that the home is well managed and organised. While the manager is overall responsible for the care aspect of the service and is registered, there is a management structure in place to ensure the smooth running of the home. Sister Jennifer, the Sister Superior is the director of the organisation and overall in charge of the home. She is also the responsible individual. She is assisted by the matron, finance manager, a maintenance manager and a quality manager. The organisation is committed to improving the quality of the service that it provides. The quality manager is responsible for ensuring governance within the service delivery. We were informed that currently the home uses the Registered Nursing Homes Association audit tool that looks at various aspects of the service. There is also monthly audits that are carried out based on the statutory monthly visits. In addition to these initiatives, there is an annual satisfaction survey that is carried out. Whilst, the quality assurance system generally works well, we advise that it is reviewed particularly with regards to the medication audit, as we did note a number of anomalies with the management of medicines that had not been identified by the medication audit. The home carries out twice yearly residents meetings and annual relatives meetings. The manager informed us that the frequency of the meetings has been decided by residents and relatives themselves. There are weekly surgeries that are arranged by the quality manager and the liaison officer of the home to provide another opportunity for residents or relatives to discuss or raise concerns and issues about the service that the home provides. The home has a finance manager. We were informed that the home does not keep any personal money for residents. Normally, residents themselves or their relatives and friends are responsible for managing their personal money. If any expenses are incurred for a resident, then the expenses are added to the monthly invoice for that resident, to be paid back to the home. Residents have a lockable facility in their bedrooms if they want to keep a small amount of personal money for their use. We looked at the management of health and safety in the home. Among the many safety certificates we noted that there were gas safety certificates for items of equipment that use gas, an electrical wiring certificate, a Portable Appliances Test certificate (PAT), LOLER certificate for the hoists and the lift, and a certificate to show that the water system was being monitored for Legionnaires disease. Care Homes for Older People Page 30 of 36 Evidence: There was evidence of weekly fire detector tests, monthly emergency lights tests, wheelchair checks and monthly monitoring of the water temperature at hot water outlets. We checked a number of hot water outlets at random and noted that thermostatic mixing valves were in place. We were informed that that the hot water was tested at each hot water outlet in the home at least once every year to check whether thermostatic mixing valves were working appropriately. This was arranged so that a number of hot water outlets, including the rooms of residents, was checked every month. However, the frequency of the maintenance of thermostatic valves and checking the temperature of water to check if the thermostatic valves are working appropriately should be according to the manufacturers instructions. The home should therefore check if its maintenance regime for the thermostatic mixing valves is compliant with the manufacturers instructions and the Thermostatic Mixing Valves Manufacturers Association. The AQAA informed us that the home has replaced a number of windows. We checked if windows on the first floor were fitted with window restrictors and noted that at least one bedroom had windows with no window restrictors. We were informed that there were about eight windows on the first floor that had windows with no restrictors. The risk of falling from a height was also not fully addressed in the health and safety risk assessment as per the guidance from the Health and safety Executive Falls from windows in health and social care. (HSE, (2007). http:/www.hse.gov.uk/lau/lacs/796.htm). It must be noted that the HSE states that the permitted level of risk of injury from falls from a height is nil or negligible. The home had a fire risk assessment and a fire emergency plan. It also had a health and safety risk assessment that were reviewed annually. Care Homes for Older People Page 31 of 36 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 32 of 36 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 The computerised care 01/03/2010 records must have a system to prevent editing and amending care records that has already been entered, without an appropriate audit trail of the original records. To ensure that the records are kept as authentic as possible. 2 7 12 The care plans for the management of pressure ulcers must address all pressure ulcers and must be clear about the frequency of the dressings. There must be photographs or wound mapping to monitor the ulcers and wound progress notes must be kept. The care plans to manage pressure ulcers or to address the needs of residents at high risk of developing pressure ulcers must be clear about the 01/03/2010 Care Homes for Older People Page 33 of 36 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action equipment to use and the repositioning regime in place. To ensure that residents receive a high standard of pressure ulcer management. 3 9 13 The appropriate lancing device for professional use must be used when testing diabetic residents for blood glucose levels To prevent cross-infection of blood borne diseases. 4 9 13 The entries and changes to 01/03/2010 medicines dosage must always be dated and signed. Ideally a new entry must be made on each occasion. To keep a clear audit trail. 5 9 13 All medicines must be administered as prescribed. Clear audit trails must be kept about the balance of the amount of medicines in stock. To evidence that residents receive medicines as prescribed. 6 38 13 There must be a risk assessment to address the risk of residents falling out of windows that can be fully opened. Control measures 06/02/2010 01/03/2010 01/03/2010 Care Homes for Older People Page 34 of 36 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action such as window restrictors must be in place if any risk is identified. To ensure the safety of all residents that live in he home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 That the frequency to review risk assessments is clarified to ensure that these are used in a proactive manner depending on the needs of residents. The care records should contain more information about the religious and spiritual needs of residents. A pain chart should be used whenever residents say that they have pain and when the pain is not easy to control. The home should make every effort to ensure that one of the employment references for applicants to work in the home, is always from the last employer. The quality assurance system should be reviewed particularly with regards to the medication audit to ensure the appropriate management of medicines in the home. The home should check if its maintenance regime for the thermostatic mixing valves is compliant with the manufacturers instructions, to make sure that the thermostatic mixing valves are maintained as required. 2 3 4 7 8 29 5 33 6 38 Care Homes for Older People Page 35 of 36 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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